Provider Demographics
NPI:1265176432
Name:LY, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC STREET HEALTH SCIENCES BUILDING B-241 B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7573
Practice Address - Country:US
Practice Address - Phone:206-543-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS110071122300000X
390200000X
WADR61678626204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program