Provider Demographics
NPI:1932365111
Name:LY, MAI TU (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAI
Middle Name:TU
Last Name:LY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 9TH ST
Mailing Address - Street 2:SUITE #302
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-6522
Mailing Address - Country:US
Mailing Address - Phone:415-269-7975
Mailing Address - Fax:
Practice Address - Street 1:345 9TH ST
Practice Address - Street 2:SUITE #302
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-6522
Practice Address - Country:US
Practice Address - Phone:415-269-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57428122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist