Healthcare Provider Details

I. General information

NPI: 1194943704
Provider Name (Legal Business Name): ZHIWEI ZHAO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W HOLT AVE STE E
POMONA CA
91768-3612
US

IV. Provider business mailing address

23620 VIA RANCHO DR
DIAMOND BAR CA
91765-2154
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-4435
  • Fax:
Mailing address:
  • Phone: 909-860-2445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52137
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number52137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: