Provider Demographics
NPI:1356358014
Name:LIU, BEN W (DMD)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:W
Last Name:LIU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127
Mailing Address - Country:US
Mailing Address - Phone:617-268-5638
Mailing Address - Fax:617-268-3387
Practice Address - Street 1:591 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127
Practice Address - Country:US
Practice Address - Phone:617-268-5638
Practice Address - Fax:617-268-3387
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice