Healthcare Provider Details

I. General information

NPI: 1649840026
Provider Name (Legal Business Name): FREDERICK LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 ATWOOD AVE STE 802
PROVIDENCE RI
02919-3289
US

IV. Provider business mailing address

1526 ATWOOD AVE STE 102
PROVIDENCE RI
02919-3289
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-4411
  • Fax:
Mailing address:
  • Phone: 401-273-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401417453
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: