=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689080632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECILIA LIU DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 11/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3071 SOUTHPORT SUPPLY RD SE
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-253-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3071 SOUTHPORT SUPPLY RD SE
-----------------------------------------------------
City | BOLIVIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28422-7943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 10481
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------