Provider Demographics
NPI:1588199491
Name:LIU, SUSAN YI
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:YI
Last Name:LIU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WATERSIDE PLZ
Mailing Address - Street 2:APT 9B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2602
Mailing Address - Country:US
Mailing Address - Phone:646-670-2801
Mailing Address - Fax:
Practice Address - Street 1:10 WATERSIDE PLZ
Practice Address - Street 2:APT 9B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2602
Practice Address - Country:US
Practice Address - Phone:646-670-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05983411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice