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General NPI Number Information
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NPI Number | 1679932032
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Entity Type | Organization
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Legal Business Name | LI DDS DENTAL INC.
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Dates
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Enumeration Date | 02/15/2016
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Last Update Date | 08/01/2016
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Provider Practice Location Address
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Address Line | 3333 S BREA CANYON RD STE 121
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City | DIAMOND BAR
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State | CA
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Zip | 91765-3783
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Country | US
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Telephone | 909-869-1098
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Fax | 909-869-7202
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Provider Business Mailing Address
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Address Line | 3333 S BREA CANYON RD STE 121
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City | DIAMOND BAR
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State | CA
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Zip | 91765-3783
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Country | US
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Telephone | 909-869-1098
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Fax | 909-869-7202
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Authorized Official
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Title or Position | CEO
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Name | JINGJING LI
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Credential | D.D.S.
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Telephone | 909-869-1098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 56851
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 46308
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 56851
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License Number State | CA
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