Provider Demographics
NPI:1013085273
Name:LIU, MARK ADAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ADAM
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 1:101 W 80TH ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-7103
Mailing Address - Country:US
Mailing Address - Phone:646-934-0000
Mailing Address - Fax:
Practice Address - Street 1:7911 41ST AVE
Practice Address - Street 2:SUITE A-107
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1258
Practice Address - Country:US
Practice Address - Phone:718-205-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02654479Medicaid