=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134039597
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL LY DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2026
-----------------------------------------------------
Last Update Date | 09/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1852 N. MASTICK WAY
-----------------------------------------------------
City | NOGALES
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-375-5032
-----------------------------------------------------
Fax | 520-377-9430
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 N GRAND AVE SUITE 100
-----------------------------------------------------
City | NOGALES
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-375-5032
-----------------------------------------------------
Fax | 520-377-9430
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D012940
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------