Provider Demographics
NPI:1639362270
Name:LY, TUAN THANH (DDS)
Entity Type:Individual
Prefix:DR
First Name:TUAN
Middle Name:THANH
Last Name:LY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13242 CORTINA
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8730
Mailing Address - Country:US
Mailing Address - Phone:714-504-4237
Mailing Address - Fax:
Practice Address - Street 1:910 E GRAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3430
Practice Address - Country:US
Practice Address - Phone:760-745-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA571691223P0221X
NY0523431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry