Provider Demographics
NPI:1073534806
Name:LEE, KYOUNG HEE SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYOUNG HEE
Middle Name:SUSAN
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26087 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6506
Mailing Address - Country:US
Mailing Address - Phone:909-799-3682
Mailing Address - Fax:
Practice Address - Street 1:570 E VIRGINIA WAY
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3910
Practice Address - Country:US
Practice Address - Phone:760-255-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93579-01Medicare ID - Type UnspecifiedDENTI-CAL PROVIDER NUMBER