Provider Demographics
NPI:1316504400
Name:LY, ELIZABETH (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:22992 LOVIOS
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2133
Mailing Address - Country:US
Mailing Address - Phone:714-383-0100
Mailing Address - Fax:
Practice Address - Street 1:17010 RED HILL AVE STE D
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5626
Practice Address - Country:US
Practice Address - Phone:949-975-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0427501223G0001X
390200000X
CADDS1049261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program