Provider Demographics
NPI:1700391810
Name:JUSTIN H. LIAO D.D.S. INC.
Entity Type:Organization
Organization Name:JUSTIN H. LIAO D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HSI CHUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LIAO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-679-4091
Mailing Address - Street 1:PO BOX 2004
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91778-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1072
Practice Address - Country:US
Practice Address - Phone:626-284-6706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty