Provider Demographics
NPI:1194943704
Name:ZHAO, ZHIWEI (DDS)
Entity type:Individual
Prefix:
First Name:ZHIWEI
Middle Name:
Last Name:ZHAO
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 1:23620 VIA RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2154
Mailing Address - Country:US
Mailing Address - Phone:909-860-2445
Mailing Address - Fax:
Practice Address - Street 1:430 W HOLT AVE STE E
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3612
Practice Address - Country:US
Practice Address - Phone:909-623-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA521371223S0112X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52137Medicaid