Healthcare Provider Details

I. General information

NPI: 1578016762
Provider Name (Legal Business Name): SHANG LUN LIU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ALLEN LIU

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 S 320TH ST
FEDERAL WAY WA
98003-5400
US

IV. Provider business mailing address

2505 S 320TH ST
FEDERAL WAY WA
98003-5400
US

V. Phone/Fax

Practice location:
  • Phone: 206-400-0800
  • Fax:
Mailing address:
  • Phone: 206-400-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE60688009
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: