Active NPI
Ly Ngoc Petrie, D.D.S.
- Dentist
- San Bernardino, CA
National Provider Identifier
1720340896
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 63273
- Practice address
- 665 N D St
San Bernardino, CA 92401-1109 - Phone
- (909) 708-8158
- NPI assigned
- Jun 13, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 63273 | CA | Primary |
Addresses
Primary practice location
665 N D St
San Bernardino, CA 92401-1109
Mailing address
11201 Benton St
Loma Linda, CA 92357-1000
Other practice location 1
1070 E Ramsey St
Banning, CA 92220-5924
Phone (951) 846-2560
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 63273 | CA | MD | Mental Health Counselor |
Interoperability endpoints
- lyn.petrie.p3@direct.parktreechc.nextgenshare.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1339545600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1607644800000",
"number": "1720340896",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11201 BENTON ST",
"city": "LOMA LINDA",
"state": "CA",
"postal_code": "923571000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "665 N D ST",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924011109",
"telephone_number": "909-708-8158"
}
],
"practiceLocations": [
{
"address_1": "1070 E Ramsey St",
"address_purpose": "LOCATION",
"city": "Banning",
"state": "CA",
"postal_code": "922205924",
"country_code": "US",
"telephone_number": "951-846-2560",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PETRIE",
"first_name": "LY",
"middle_name": "NGOC",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-06-13",
"last_updated": "2020-12-11",
"certification_date": "2020-12-11",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "63273",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Bernardino, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.