Provider Demographics
NPI:1043387228
Name:LY, TUANKIET QUOC (DDS)
Entity type:Individual
Prefix:
First Name:TUANKIET
Middle Name:QUOC
Last Name:LY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3430
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-3430
Mailing Address - Country:US
Mailing Address - Phone:310-835-3131
Mailing Address - Fax:
Practice Address - Street 1:1610 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1431
Practice Address - Country:US
Practice Address - Phone:310-835-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice