MEDICARE: DR. BRIAN LY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	100738	CA

General Provider Information

NPI Number	:	1831649185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN LY D.D.S.

Provider Business Mailing Address
First Line	:	293 N STATE COLLEGE BLVD
Second Line	:	APT 1017
City	:	ORANGE
State	:	CA
Zip	:	92868-5700
Country	:	US
Telephone Number	:	310-658-0620
Fax Number	:

Provider Business Practice Location Address
First Line	:	293 N STATE COLLEGE BLVD
Second Line	:	APT 1017
City	:	ORANGE
State	:	CA
Zip	:	92868-5700
Country	:	US
Telephone Number	:	310-658-0620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2016
Last Update Date	:	10/11/2016

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