Provider Demographics
NPI:1205560497
Name:LIU, XINGTONG
Entity type:Individual
Prefix:
First Name:XINGTONG
Middle Name:
Last Name:LIU
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 1:340 E 23RD ST APT 4I
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4746
Mailing Address - Country:US
Mailing Address - Phone:917-783-3259
Mailing Address - Fax:
Practice Address - Street 1:2702 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4950
Practice Address - Country:US
Practice Address - Phone:618-993-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0338671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice