Individual
LI BAO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
475 COORS BLVD NW STE A, ALBUQUERQUE, NM 87121-1426
(505) 208-0505
Mailing address
475 COORS BLVD NW STE A, ALBUQUERQUE, NM 87121-1426
(505) 208-0505
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
63209
CA
122300000X
Dentist
DD4029
NM
1223G0001X
General Practice Dentistry
DD4029
NM
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DD4029
NM
Other
Enumeration date
01/07/2014
Last updated
08/06/2024
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