Provider Demographics
NPI:1841742319
Name:LIY, RAPHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:
Last Name:LIY
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 1:1822 HEALTH CARE DR BLDG 6
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5362
Mailing Address - Country:US
Mailing Address - Phone:727-848-5525
Mailing Address - Fax:
Practice Address - Street 1:1822 HEALTH CARE DR BLDG 6
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5362
Practice Address - Country:US
Practice Address - Phone:727-848-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-435-16122300000X
FLDN242831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist