Healthcare Provider Details

I. General information

NPI: 1306903471
Provider Name (Legal Business Name): CONNIE LIU D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 MAIN ST 4TH FLOOR
FLUSHING NY
11354-6509
US

IV. Provider business mailing address

322 W 55TH ST APT# 2B
NEW YORK NY
10019-5157
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-7222
  • Fax:
Mailing address:
  • Phone: 917-609-2735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051204
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: