Healthcare Provider Details

I. General information

NPI: 1699310516
Provider Name (Legal Business Name): ANN LIU LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 N 18TH ST
KENILWORTH NJ
07033-1230
US

IV. Provider business mailing address

68 4TH ST APT 2A
SOUTH ORANGE NJ
07079-1851
US

V. Phone/Fax

Practice location:
  • Phone: 908-272-4170
  • Fax: 908-272-1420
Mailing address:
  • Phone: 832-264-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANN LIU
Title or Position: OWNER
Credential: DMD
Phone: 832-264-1360