Provider Demographics
NPI:1033626171
Name:MA, LI (DDS)
Entity Type:Individual
Prefix:DR
First Name:LI
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ROUTE 25A STE 1
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2821
Mailing Address - Country:US
Mailing Address - Phone:631-905-6061
Mailing Address - Fax:631-905-6061
Practice Address - Street 1:45 ROUTE 25A STE 1
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2821
Practice Address - Country:US
Practice Address - Phone:631-905-6061
Practice Address - Fax:631-905-6061
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice