=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255059044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XIE & LIU DENTAL PARTNERSHIP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2022
-----------------------------------------------------
Last Update Date | 08/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 PACIFICA STE 350
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-247-4258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24970 KEISSEL RD
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-9687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-247-4258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. GARY LIU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 909-247-4258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------