Provider Demographics
NPI:1164987673
Name:GUNDONG LEE DDS, INC
Entity Type:Organization
Organization Name:GUNDONG LEE DDS, INC
Other - Org Name:REAL DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GUNDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-800-1994
Mailing Address - Street 1:1235 N HARBOR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1323
Mailing Address - Country:US
Mailing Address - Phone:714-525-2888
Mailing Address - Fax:
Practice Address - Street 1:1235 N HARBOR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1323
Practice Address - Country:US
Practice Address - Phone:714-525-2888
Practice Address - Fax:714-525-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366812026Medicaid