Provider Demographics
NPI:1720125966
Name:LY, PHAT T (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHAT
Middle Name:T
Last Name:LY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8507 S 5TH ST # A-101
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-3421
Mailing Address - Country:US
Mailing Address - Phone:360-887-2310
Mailing Address - Fax:360-887-2309
Practice Address - Street 1:8507 S 5TH ST # A-101
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3421
Practice Address - Country:US
Practice Address - Phone:360-887-2310
Practice Address - Fax:360-887-2309
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047634Medicaid