Provider Demographics
NPI:1689882425
Name:LIU, KWANG-TA (DDS)
Entity Type:Individual
Prefix:
First Name:KWANG-TA
Middle Name:
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 1:1150 SCOTT BLVD STE C1
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4547
Mailing Address - Country:US
Mailing Address - Phone:408-554-1655
Mailing Address - Fax:408-554-1659
Practice Address - Street 1:1150 SCOTT BLVD STE C1
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4547
Practice Address - Country:US
Practice Address - Phone:408-554-1655
Practice Address - Fax:408-554-1659
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice