Provider Demographics
NPI:1124183140
Name:LI, IVY X (DDS)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:X
Last Name:LI
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 1:945 W DUARTE RD
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4306
Mailing Address - Country:US
Mailing Address - Phone:626-445-2178
Mailing Address - Fax:
Practice Address - Street 1:945 W DUARTE RD
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-4306
Practice Address - Country:US
Practice Address - Phone:626-445-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124183140OtherNPI