Healthcare Provider Details

I. General information

NPI: 1134039597
Provider Name (Legal Business Name): CRYSTAL LY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 N. MASTICK WAY
NOGALES AZ
85621
US

IV. Provider business mailing address

825 N GRAND AVE SUITE 100
NOGALES AZ
85621
US

V. Phone/Fax

Practice location:
  • Phone: 520-375-5032
  • Fax: 520-377-9430
Mailing address:
  • Phone: 520-375-5032
  • Fax: 520-377-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012940
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: