Healthcare Provider Details

I. General information

NPI: 1366038499
Provider Name (Legal Business Name): RAPHAEL LIY DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2020
Last Update Date: 02/02/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 HEALTH CARE DR BLDG 6
TRINITY FL
34655-5362
US

IV. Provider business mailing address

1822 HEALTH CARE DR BLDG 6
TRINITY FL
34655-5362
US

V. Phone/Fax

Practice location:
  • Phone: 727-848-5525
  • Fax:
Mailing address:
  • Phone: 727-848-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RAPHAEL LIY
Title or Position: MANAGER
Credential: DDS
Phone: 727-848-5525