Provider Demographics
NPI:1508351909
Name:LIU, CLARISSA GAPO (RDH)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:GAPO
Last Name:LIU
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:GAPO
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 13725
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-0725
Mailing Address - Country:US
Mailing Address - Phone:503-830-0449
Mailing Address - Fax:
Practice Address - Street 1:700 NE MULTNOMAH ST STE 850
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-4108
Practice Address - Country:US
Practice Address - Phone:503-230-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5147124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist