Provider Demographics
NPI:1467505651
Name:LIU, MOLLY SAN SI HSAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:SAN SI HSAM
Last Name:LIU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:S
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:6621 WESLEY PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4825
Mailing Address - Country:US
Mailing Address - Phone:619-469-9473
Mailing Address - Fax:
Practice Address - Street 1:5527 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-2342
Practice Address - Country:US
Practice Address - Phone:858-467-0503
Practice Address - Fax:858-467-9103
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91634-01Medicaid