Provider Demographics
NPI:1215071840
Name:LY, DONG-PHUONG T (DMD)
Entity type:Individual
Prefix:
First Name:DONG-PHUONG
Middle Name:T
Last Name:LY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N GLEBE RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-3728
Mailing Address - Country:US
Mailing Address - Phone:703-248-1111
Mailing Address - Fax:
Practice Address - Street 1:200 N GLEBE RD
Practice Address - Street 2:SUITE 225
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-3728
Practice Address - Country:US
Practice Address - Phone:703-248-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410253122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist