Provider Demographics
NPI:1982770491
Name:LI, IVY OI-WAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:OI-WAN
Last Name:LI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ORD ST
Mailing Address - Street 2:SUITE #102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2834
Mailing Address - Country:US
Mailing Address - Phone:213-617-0136
Mailing Address - Fax:
Practice Address - Street 1:420 ORD ST
Practice Address - Street 2:SUITE #102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2834
Practice Address - Country:US
Practice Address - Phone:213-617-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA266741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice