Healthcare Provider Details

I. General information

NPI: 1245488394
Provider Name (Legal Business Name): THI TO NHU LY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST FL 7
BOSTON MA
02118-2545
US

IV. Provider business mailing address

100 E NEWTON ST FL 7
BOSTON MA
02118-2545
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-4705
  • Fax: 617-638-4713
Mailing address:
  • Phone: 617-638-4705
  • Fax: 617-638-4713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10141
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: