MEDICARE: DR. KY L DO DDS

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	41399	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900200438	OTHER	CA	DENTISTRY

General Provider Information

NPI Number	:	1255428058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KY L DO DDS

Provider Business Mailing Address
First Line	:	12072 VALLEY BLVD
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732-3137
Country	:	US
Telephone Number	:	626-527-2200
Fax Number	:	626-527-2205

Provider Business Practice Location Address
First Line	:	12072 VALLEY BLVD
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732-3137
Country	:	US
Telephone Number	:	626-527-2200
Fax Number	:	626-527-2205

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	09/08/2015

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