MEDICARE: DR. KHANG-LEE LIU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	19-15218	IL

General Provider Information

NPI Number	:	1083696066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHANG-LEE LIU DDS

Provider Business Mailing Address
First Line	:	2158-B S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1514
Country	:	US
Telephone Number	:	312-225-2222
Fax Number	:	312-225-2219

Provider Business Practice Location Address
First Line	:	2158-B S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1514
Country	:	US
Telephone Number	:	312-225-2222
Fax Number	:	312-225-2219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	07/08/2007

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