Healthcare Provider Details

I. General information

NPI: 1114411261
Provider Name (Legal Business Name): LY KHANH HUYNH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 10/06/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15409 W GREENWAY RD STE 100
SURPRISE AZ
85374-4368
US

IV. Provider business mailing address

15409 W GREENWAY RD STE 100
SURPRISE AZ
85374-4368
US

V. Phone/Fax

Practice location:
  • Phone: 623-546-3511
  • Fax:
Mailing address:
  • Phone: 623-546-3511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD010061
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: