Provider Demographics
NPI:1790211506
Name:LI, XIAO
Entity Type:Individual
Prefix:
First Name:XIAO
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4320
Mailing Address - Country:US
Mailing Address - Phone:408-896-3562
Mailing Address - Fax:
Practice Address - Street 1:1315 S WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4320
Practice Address - Country:US
Practice Address - Phone:408-866-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
CA1027721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program