Provider Demographics
NPI: | 1164714481 |
---|---|
Name: | CSLEE, DMD,MMSC,PLLC |
Entity Type: | Organization |
Organization Name: | CSLEE, DMD,MMSC,PLLC |
Other - Org Name: | OMNIDENTIX |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | CHONG |
Authorized Official - Middle Name: | S |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 508-807-4736 |
Mailing Address - Street 1: | 555 BEDFORD ST |
Mailing Address - Street 2: | UNIT 3 |
Mailing Address - City: | BRIDGEWATER |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02324 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-807-4736 |
Mailing Address - Fax: | 508-807-4743 |
Practice Address - Street 1: | 555 BEDFORD ST |
Practice Address - Street 2: | UNIT 3 |
Practice Address - City: | BRIDGEWATER |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02324 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-807-4736 |
Practice Address - Fax: | 508-807-4743 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-05-04 |
Last Update Date: | 2020-02-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 18866 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |