Provider Demographics
NPI:1417297946
Name:LI, QINGSHAN (DMD)
Entity Type:Individual
Prefix:
First Name:QINGSHAN
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 W 15TH ST APT A1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3100
Mailing Address - Country:US
Mailing Address - Phone:216-835-4837
Mailing Address - Fax:
Practice Address - Street 1:51 W 15TH ST. UNIT A1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3100
Practice Address - Country:US
Practice Address - Phone:216-835-4837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist