Provider Demographics
NPI:1063003051
Name:LI, JIAWEI
Entity Type:Individual
Prefix:
First Name:JIAWEI
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 S BROADWAY UNIT 2305
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 SIXTH AVE STE 125
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3893
Practice Address - Country:US
Practice Address - Phone:650-592-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist