Healthcare Provider Details

I. General information

NPI: 1821367079
Provider Name (Legal Business Name): GARY C LYON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3932 LONG BEACH BLVD SUITE A
LONG BEACH CA
90807-2615
US

IV. Provider business mailing address

3932 LONG BEACH BLVD SUITE A
LONG BEACH CA
90807-2615
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-3890
  • Fax:
Mailing address:
  • Phone: 562-427-3890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: