Provider Demographics
NPI:1255302022
Name:LY, BLONG ROGER (DDS)
Entity Type:Individual
Prefix:
First Name:BLONG
Middle Name:ROGER
Last Name:LY
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 1:5100 O'BYRNES FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95327
Mailing Address - Country:US
Mailing Address - Phone:209-984-5291
Mailing Address - Fax:
Practice Address - Street 1:5100 OBYRNES FERRY RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327-9102
Practice Address - Country:US
Practice Address - Phone:209-984-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist