Healthcare Provider Details

I. General information

NPI: 1649878034
Provider Name (Legal Business Name): SOH OF MISSOURI SAMSON LIU PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 OFALLON RD STE 70
WELDON SPRING MO
63304-8107
US

IV. Provider business mailing address

810 OFALLON RD STE 70
WELDON SPRING MO
63304-8107
US

V. Phone/Fax

Practice location:
  • Phone: 636-244-4052
  • Fax:
Mailing address:
  • Phone: 636-244-4052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SAMSON LIU
Title or Position: CEO
Credential:
Phone: 217-821-7960