MEDICARE: OANH THI LY 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	47519	CA

General Provider Information

NPI Number	:	1518217587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OANH THI LY DDS

Provider Business Mailing Address
First Line	:	23635 EL TORO RD
Second Line	:	SUITE H3
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4748
Country	:	US
Telephone Number	:	949-951-4885
Fax Number	:	949-951-1538

Provider Business Practice Location Address
First Line	:	23635 EL TORO RD
Second Line	:	SUITE H3
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4748
Country	:	US
Telephone Number	:	949-951-4885
Fax Number	:	949-951-1538

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

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	09/17/2012

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