Healthcare Provider Details

I. General information

NPI: 1629506043
Provider Name (Legal Business Name): SECURE DENTAL V
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 05/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 RIVERSIDE DR
EAST PEORIA IL
61611-2068
US

IV. Provider business mailing address

309 BROOKSTONE DR
EAST PEORIA IL
61611-8300
US

V. Phone/Fax

Practice location:
  • Phone: 309-681-8888
  • Fax:
Mailing address:
  • Phone: 847-874-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NOEL LIU
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 815-670-2923