Provider Demographics
NPI:1790131761
Name:LY, PHONG (DDS)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:
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 1:9920 FOLEY BLVD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5216
Mailing Address - Country:US
Mailing Address - Phone:763-317-1166
Mailing Address - Fax:
Practice Address - Street 1:9920 FOLEY BLVD NW STE 110
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5216
Practice Address - Country:US
Practice Address - Phone:763-377-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist