Provider Demographics
NPI:1609930007
Name:LIU, NATHANIEL S (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:S
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 1:28350 VIA SANTA ROSA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5335
Mailing Address - Country:US
Mailing Address - Phone:619-259-4001
Mailing Address - Fax:
Practice Address - Street 1:28350 VIA SANTA ROSA
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5335
Practice Address - Country:US
Practice Address - Phone:619-259-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9242601Medicaid
CAG9818801OtherHEALTHY FAMILIES
CA924775OtherUNITED CONCORDIA