Provider Demographics
NPI:1124205455
Name:LI, MIKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:
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 1:1108 VICENTE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-3042
Mailing Address - Country:US
Mailing Address - Phone:415-753-6161
Mailing Address - Fax:415-753-0208
Practice Address - Street 1:1108 VICENTE ST STE 104
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-3042
Practice Address - Country:US
Practice Address - Phone:415-753-6161
Practice Address - Fax:415-753-0208
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52636122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2023547OtherUNITED CONCORDIA