Provider Demographics
NPI:1518296391
Name:LY, TRUNG (RDH)
Entity Type:Individual
Prefix:
First Name:TRUNG
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7807 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-2037
Mailing Address - Country:US
Mailing Address - Phone:916-383-2758
Mailing Address - Fax:
Practice Address - Street 1:9320 ELK GROVE BLVD
Practice Address - Street 2:STE. 170
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5062
Practice Address - Country:US
Practice Address - Phone:916-714-5422
Practice Address - Fax:916-714-5429
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23972124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist