Provider Demographics
NPI:1629506043
Name:SECURE DENTAL V
Entity Type:Organization
Organization Name:SECURE DENTAL V
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-670-2923
Mailing Address - Street 1:309 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-8300
Mailing Address - Country:US
Mailing Address - Phone:847-874-7276
Mailing Address - Fax:
Practice Address - Street 1:504 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2068
Practice Address - Country:US
Practice Address - Phone:309-681-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental