Provider Demographics
NPI:1467939793
Name:LY, VINH Q (DMD)
Entity Type:Individual
Prefix:DR
First Name:VINH
Middle Name:Q
Last Name:LY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 JOHN F KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1614
Mailing Address - Country:US
Mailing Address - Phone:717-826-1400
Mailing Address - Fax:
Practice Address - Street 1:3630 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-3204
Practice Address - Country:US
Practice Address - Phone:201-222-5288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027241001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice