Provider Demographics
NPI:1336871409
Name:LI, GUANGILN (DMD)
Entity Type:Individual
Prefix:
First Name:GUANGILN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 LAS COLINAS BLVD APT 5100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4697
Mailing Address - Country:US
Mailing Address - Phone:571-234-7740
Mailing Address - Fax:
Practice Address - Street 1:3710 S CARRIER PKWY STE 100
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6637
Practice Address - Country:US
Practice Address - Phone:972-349-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX385891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice