Healthcare Provider Details

I. General information

NPI: 1639103724
Provider Name (Legal Business Name): CHARLES(CHIAHO) LIU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2558 W 4TH ST
ONTARIO OH
44906-1209
US

IV. Provider business mailing address

2558 W 4TH ST
ONTARIO OH
44906-1209
US

V. Phone/Fax

Practice location:
  • Phone: 419-683-3131
  • Fax:
Mailing address:
  • Phone: 419-683-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number20402
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-02-20402
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: