Provider Demographics
NPI:1629277900
Name:LY, MAI XUAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAI
Middle Name:XUAN
Last Name:LY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12561 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2832
Mailing Address - Country:US
Mailing Address - Phone:714-878-0597
Mailing Address - Fax:
Practice Address - Street 1:12561 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2832
Practice Address - Country:US
Practice Address - Phone:714-878-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice