Provider Demographics
NPI:1033241161
Name:LIU, KENNY (DDS)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 CEDAR ST APT A
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1810
Mailing Address - Country:US
Mailing Address - Phone:661-496-9355
Mailing Address - Fax:
Practice Address - Street 1:1898 CEDAR ST APT A
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1810
Practice Address - Country:US
Practice Address - Phone:661-496-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA538221223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD53822OtherDENTI-CAL PROVIDER NUMBER