Provider Demographics
NPI:1831649185
Name:LY, BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
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 1:293 N STATE COLLEGE BLVD
Mailing Address - Street 2:APT 1017
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-5700
Mailing Address - Country:US
Mailing Address - Phone:310-658-0620
Mailing Address - Fax:
Practice Address - Street 1:293 N STATE COLLEGE BLVD
Practice Address - Street 2:APT 1017
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-5700
Practice Address - Country:US
Practice Address - Phone:310-658-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1007381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice