Provider Demographics
NPI:1073901849
Name:CHANGRUI LIU, D.D.S., INC., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CHANGRUI LIU, D.D.S., INC., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANGRUI
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-560-8889
Mailing Address - Street 1:5601 KANAN RD
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-3358
Mailing Address - Country:US
Mailing Address - Phone:310-560-8889
Mailing Address - Fax:
Practice Address - Street 1:11600 WILSHIRE BLVD,
Practice Address - Street 2:#316
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1783
Practice Address - Country:US
Practice Address - Phone:310-560-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGRUI LIU, D.D.S., INC., A PROFESSIONAL CORPARATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty