Provider Demographics
NPI:1104008523
Name:LY, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 N LOS ROBLES AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1301
Mailing Address - Country:US
Mailing Address - Phone:626-731-8520
Mailing Address - Fax:
Practice Address - Street 1:255 N ROSEMEAD BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3102
Practice Address - Country:US
Practice Address - Phone:626-731-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA564461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice