Healthcare Provider Details

I. General information

NPI: 1205560497
Provider Name (Legal Business Name): XINGTONG LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 W DEYOUNG ST
MARION IL
62959-4950
US

IV. Provider business mailing address

340 E 23RD ST APT 4I
NEW YORK NY
10010-4746
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-9092
  • Fax:
Mailing address:
  • Phone: 917-783-3259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2022047981
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033867
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: