Provider Demographics
NPI:1811666464
Name:LY, AN THI KHANH
Entity type:Individual
Prefix:
First Name:AN
Middle Name:THI KHANH
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 1:5021 TAFT BLVD APT 1103
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5370
Mailing Address - Country:US
Mailing Address - Phone:214-606-5715
Mailing Address - Fax:
Practice Address - Street 1:3711 GREGORY ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1614
Practice Address - Country:US
Practice Address - Phone:940-386-6029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX378421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice