Provider Demographics
NPI:1134279029
Name:LI, MIRANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
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 1:300 W VALLEY BLVD STE D83
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3338
Mailing Address - Country:US
Mailing Address - Phone:626-765-7152
Mailing Address - Fax:
Practice Address - Street 1:328 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1708
Practice Address - Country:US
Practice Address - Phone:626-288-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice