Provider Demographics
NPI:1073950747
Name:LI, MICHAEL C (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:LI
Suffix:
Gender:M
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:PO BOX 2159
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92593-2159
Mailing Address - Country:US
Mailing Address - Phone:617-834-2683
Mailing Address - Fax:
Practice Address - Street 1:29560 RANCHO CALIFORNIA RD STE 100
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5294
Practice Address - Country:US
Practice Address - Phone:617-834-2683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA633551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics