Provider Demographics
NPI:1679803241
Name:TK LY DENTAL CORPORATION
Entity Type:Organization
Organization Name:TK LY DENTAL CORPORATION
Other - Org Name:BAY MESA DENTAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TUANKIET
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-646-9000
Mailing Address - Street 1:2023 HARBOR BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5552
Mailing Address - Country:US
Mailing Address - Phone:949-646-9000
Mailing Address - Fax:
Practice Address - Street 1:2023 HARBOR BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5552
Practice Address - Country:US
Practice Address - Phone:949-646-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48322OtherDENTAL BOARD OF CALIFORNIA
CA1043387228OtherNATIONAL PROVIDER IDENTIFIER