MEDICARE: LI & NGUYEN DENTAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1750052965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LI & NGUYEN DENTAL CORP

Provider Business Mailing Address
First Line	:	3333 S BREA CANYON RD STE 121
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-3783
Country	:	US
Telephone Number	:	909-869-1098
Fax Number	:

Provider Business Practice Location Address
First Line	:	2707 E VALLEY BLVD STE 301
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3198
Country	:	US
Telephone Number	:	909-908-8905
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JINGJING LI
Credential	:
Telephone Number	:	909-908-8905

Provider Enumeration Date	:	09/27/2021
Last Update Date	:	09/27/2021

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Directions to “LI & NGUYEN DENTAL CORP ” Practice Location

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