Provider Demographics
NPI:1245419316
Name:LY, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 AREZZO DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2204
Mailing Address - Country:US
Mailing Address - Phone:408-705-6024
Mailing Address - Fax:
Practice Address - Street 1:55 E JULIAN ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4007
Practice Address - Country:US
Practice Address - Phone:408-918-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA560601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice