Provider Demographics
NPI:1114317690
Name:BADII LEE DENTAL CORPORATION, INC.
Entity Type:Organization
Organization Name:BADII LEE DENTAL CORPORATION, INC.
Other - Org Name:SMILE WIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIAVASH
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:BADII
Authorized Official - Suffix:
Authorized Official - Credentials:54538
Authorized Official - Phone:949-596-8100
Mailing Address - Street 1:1920 MAIN ST STE 970
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-8275
Mailing Address - Country:US
Mailing Address - Phone:949-596-8100
Mailing Address - Fax:562-424-9807
Practice Address - Street 1:4024 12TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3561
Practice Address - Country:US
Practice Address - Phone:951-784-0636
Practice Address - Fax:951-784-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty