Healthcare Provider Details

I. General information

NPI: 1487039152
Provider Name (Legal Business Name): MITZI LIU DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST FL 11
BOSTON MA
02111-1527
US

IV. Provider business mailing address

55 OAK ST # 502
SAN FRANCISCO CA
94102-6010
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6887
  • Fax:
Mailing address:
  • Phone: 503-380-5036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS106182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: