MEDICARE: DR. MICHAEL LY D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	56446	CA

General Provider Information

NPI Number	:	1104008523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LY D.M.D

Provider Business Mailing Address
First Line	:	455 N LOS ROBLES AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-1301
Country	:	US
Telephone Number	:	626-731-8520
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 N ROSEMEAD BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-3102
Country	:	US
Telephone Number	:	626-731-8520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	08/05/2008

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