Provider Demographics
NPI:1720221310
Name:LIU, MARCUS (DMD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 82ND ST APT 5D
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3529
Mailing Address - Country:US
Mailing Address - Phone:917-682-8068
Mailing Address - Fax:
Practice Address - Street 1:4210 82ND ST APT 5D
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3529
Practice Address - Country:US
Practice Address - Phone:917-682-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-12
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0550151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program