Provider Demographics
NPI:1396478228
Name:LIU, JESSICA R (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:LIU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 N ARIZONA BLVD
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85128-3215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 N ARIZONA BLVD
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-3215
Practice Address - Country:US
Practice Address - Phone:520-723-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
AZD0118271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty