Provider Demographics
NPI:1730501032
Name:BAO, LI (DMD)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:BAO
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 1:475 COORS BLVD NW STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-1426
Mailing Address - Country:US
Mailing Address - Phone:505-208-0505
Mailing Address - Fax:
Practice Address - Street 1:475 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-1426
Practice Address - Country:US
Practice Address - Phone:505-208-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63209122300000X
NMDD4029122300000X, 1223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice