=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265681266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LIEM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2008
-----------------------------------------------------
Last Update Date | 02/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2762 PINOLE VALLEY RD
-----------------------------------------------------
City | PINOLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94564-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-899-4175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23683
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-899-4175
-----------------------------------------------------
Fax | 925-899-4175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 60545
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 054566
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------