Provider Demographics
NPI:1306417860
Name:LY, KIM M
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
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 1:800 S HARVARD BLVD APT 309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4261
Mailing Address - Country:US
Mailing Address - Phone:408-717-0496
Mailing Address - Fax:
Practice Address - Street 1:5015 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3116
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1064851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice