Provider Demographics
NPI:1184463440
Name:LY, SREYNEANG
Entity type:Individual
Prefix:
First Name:SREYNEANG
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 RIO VISTA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-2901
Mailing Address - Country:US
Mailing Address - Phone:781-460-8451
Mailing Address - Fax:
Practice Address - Street 1:200 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1114
Practice Address - Country:US
Practice Address - Phone:781-687-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADA10398126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant