Provider Demographics
NPI:1841958626
Name:PHAT LY DMD PLLC
Entity type:Organization
Organization Name:PHAT LY DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-213-6041
Mailing Address - Street 1:8507 S 5TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-3422
Mailing Address - Country:US
Mailing Address - Phone:360-887-2310
Mailing Address - Fax:
Practice Address - Street 1:8507 S 5TH ST STE 101
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3422
Practice Address - Country:US
Practice Address - Phone:360-887-2310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty