=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902200066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE SHIAO, DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2014
-----------------------------------------------------
Last Update Date | 10/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2160 W GRANT LINE RD SUITE 220
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95377-7330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-835-8754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2160 W GRANT LINE RD SUITE 220
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95377-7330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-835-8754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. JANICE LIAO
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 925-640-9546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 50949
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------