Provider Demographics
NPI:1073174884
Name:LY, AN NGOC (DMD)
Entity Type:Individual
Prefix:
First Name:AN
Middle Name:NGOC
Last Name:LY
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 1:1125 S TORRY PL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4924
Mailing Address - Country:US
Mailing Address - Phone:714-818-3520
Mailing Address - Fax:
Practice Address - Street 1:27412 ANTONIO PKWY STE R4
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-2164
Practice Address - Country:US
Practice Address - Phone:949-347-7083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352581223G0001X
CA1048811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice