Provider Demographics
NPI:1669534442
Name:LIU, YIWEN (DDS)
Entity type:Individual
Prefix:DR
First Name:YIWEN
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 BELOIT AVE #304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6263
Mailing Address - Country:US
Mailing Address - Phone:310-486-9989
Mailing Address - Fax:310-478-3535
Practice Address - Street 1:11103 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6914
Practice Address - Country:US
Practice Address - Phone:310-559-9191
Practice Address - Fax:310-559-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93826-01OtherDENTI-CAL PROVIDER ID
CA5576OtherMDG HMO ID#