Provider Demographics
NPI:1639467616
Name:LY, MEGAN B (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:B
Last Name:LY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 E LINCOLN AVE
Mailing Address - Street 2:APT 260
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4258
Mailing Address - Country:US
Mailing Address - Phone:609-665-9406
Mailing Address - Fax:
Practice Address - Street 1:1013 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-4921
Practice Address - Country:US
Practice Address - Phone:626-960-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS61784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist