Provider Demographics
NPI:1164675195
Name:CHONG IL LEE D.D.S A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CHONG IL LEE D.D.S A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHONG
Authorized Official - Middle Name:IL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-983-9325
Mailing Address - Street 1:1739 S EUCLID AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-5831
Mailing Address - Country:US
Mailing Address - Phone:909-983-9325
Mailing Address - Fax:909-467-9956
Practice Address - Street 1:1739 S EUCLID AVE STE A
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-5831
Practice Address - Country:US
Practice Address - Phone:909-983-9325
Practice Address - Fax:909-467-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB25931261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental