Provider Demographics
NPI:1255993754
Name:LI, CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W VALLEY BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2472
Mailing Address - Country:US
Mailing Address - Phone:626-927-8872
Mailing Address - Fax:
Practice Address - Street 1:1101 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-2462
Practice Address - Country:US
Practice Address - Phone:626-927-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice