Provider Demographics
NPI:1265554877
Name:LY, TRI HUONG (DDS)
Entity type:Individual
Prefix:
First Name:TRI
Middle Name:HUONG
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 1:3654 GRAVOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4728
Mailing Address - Country:US
Mailing Address - Phone:314-865-3838
Mailing Address - Fax:314-865-2419
Practice Address - Street 1:3654 GRAVOIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4728
Practice Address - Country:US
Practice Address - Phone:314-865-3838
Practice Address - Fax:314-865-2419
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200-101-13471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice