Healthcare Provider Details

I. General information

NPI: 1730501032
Provider Name (Legal Business Name): LI BAO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 COORS BLVD NW STE A
ALBUQUERQUE NM
87121-1426
US

IV. Provider business mailing address

475 COORS BLVD NW STE A
ALBUQUERQUE NM
87121-1426
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-0505
  • Fax:
Mailing address:
  • Phone: 505-208-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number63209
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4029
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4029
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD4029
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: