Provider Demographics
NPI:1134486715
Name:LIU, WANYU
Entity type:Individual
Prefix:
First Name:WANYU
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 HORSEBLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2545
Mailing Address - Country:US
Mailing Address - Phone:631-730-5255
Mailing Address - Fax:631-730-5256
Practice Address - Street 1:3201 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2545
Practice Address - Country:US
Practice Address - Phone:631-730-5255
Practice Address - Fax:631-730-5256
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056835122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist