Healthcare Provider Details

I. General information

NPI: 1679932032
Provider Name (Legal Business Name): LI DDS DENTAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 S BREA CANYON RD STE 121
DIAMOND BAR CA
91765-3783
US

IV. Provider business mailing address

3333 S BREA CANYON RD STE 121
DIAMOND BAR CA
91765-3783
US

V. Phone/Fax

Practice location:
  • Phone: 909-869-1098
  • Fax: 909-869-7202
Mailing address:
  • Phone: 909-869-1098
  • Fax: 909-869-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number56851
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number56851
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number46308
License Number StateCA

VIII. Authorized Official

Name: JINGJING LI
Title or Position: CEO
Credential: D.D.S.
Phone: 909-869-1098