Provider Demographics
NPI:1962374470
Name:THACH, LILLY IHA (MDT, LDH)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:IHA
Last Name:THACH
Suffix:
Gender:F
Credentials:MDT, LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 WILLOW BND
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3969
Mailing Address - Country:US
Mailing Address - Phone:763-762-8916
Mailing Address - Fax:
Practice Address - Street 1:331 WILLOW BND
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3969
Practice Address - Country:US
Practice Address - Phone:763-762-8916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT192125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty