MEDICARE: LY DENTAL CORPORATION

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	40665	CA

General Provider Information

NPI Number	:	1316495880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LY DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	9938 BOLSA AVE STE 106
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6039
Country	:	US
Telephone Number	:	714-305-5199
Fax Number	:

Provider Business Practice Location Address
First Line	:	9938 BOLSA AVE STE 106
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6039
Country	:	US
Telephone Number	:	714-305-5199
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. QUY VAN LY
Credential	:	DDS
Telephone Number	:	714-305-5199

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	09/14/2016

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Directions to “LY DENTAL CORPORATION ” Practice Location

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