Provider Demographics
NPI:1417239666
Name:CHA, LILY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:LILY
Middle Name:E
Last Name:CHA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:201 SAN PEDRO DR SE
Practice Address - Street 2:SUITE B-2 (505) 232-5437
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3009
Practice Address - Country:US
Practice Address - Phone:505-232-5437
Practice Address - Fax:505-254-7649
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43507573Medicaid