Provider Demographics
NPI:1417186925
Name:LI, CHUAN
Entity Type:Individual
Prefix:DR
First Name:CHUAN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300N MAYFAIR RD 920
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1519
Mailing Address - Country:US
Mailing Address - Phone:414-257-1230
Mailing Address - Fax:
Practice Address - Street 1:5675 N FRONT ST STE 50
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120
Practice Address - Country:US
Practice Address - Phone:617-372-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6488-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice