Provider Demographics
NPI:1851928360
Name:DE LA TORRE, LIANA
Entity Type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:DE LA TORRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 W 75TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3737
Mailing Address - Country:US
Mailing Address - Phone:860-840-6007
Mailing Address - Fax:
Practice Address - Street 1:7633 E JEFFERSON AVE STE 70
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3730
Practice Address - Country:US
Practice Address - Phone:860-840-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI29016005801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program