Healthcare Provider Details

I. General information

NPI: 1972941292
Provider Name (Legal Business Name): TONY TIAN LIAN LI DDS, MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2013
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 N MARENGO AVE #401
PASADENA CA
91101-4509
US

IV. Provider business mailing address

163 N MARENGO AVE #401
PASADENA CA
91101-4509
US

V. Phone/Fax

Practice location:
  • Phone: 510-875-3243
  • Fax:
Mailing address:
  • Phone: 510-875-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT201468
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number57935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: