Provider Demographics
NPI:1184030066
Name:LI, WEICHUN (DMD)
Entity Type:Individual
Prefix:
First Name:WEICHUN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 SUMMER ST APT 11
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-5626
Mailing Address - Country:US
Mailing Address - Phone:617-800-6175
Mailing Address - Fax:
Practice Address - Street 1:85 RIVER ST # 65292
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-8300
Practice Address - Country:US
Practice Address - Phone:781-891-7737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18567091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice