Provider Demographics
NPI:1871646992
Name:LIU, KOFENG (DDS)
Entity Type:Individual
Prefix:
First Name:KOFENG
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 1:3915 MAIN ST
Mailing Address - Street 2:SUITE100
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3915 MAIN ST
Practice Address - Street 2:SUITE100
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5431
Practice Address - Country:US
Practice Address - Phone:718-353-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048253122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01960796Medicaid