Provider Demographics
NPI:1235122243
Name:LEE, BEOM MO (DDS)
Entity Type:Individual
Prefix:DR
First Name:BEOM
Middle Name:MO
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 S WESTERN AVE
Mailing Address - Street 2:#207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1013
Mailing Address - Country:US
Mailing Address - Phone:323-734-3710
Mailing Address - Fax:323-734-2117
Practice Address - Street 1:966 S WESTERN AVE
Practice Address - Street 2:#207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-1013
Practice Address - Country:US
Practice Address - Phone:323-734-3710
Practice Address - Fax:323-734-2117
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB46284122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4628401Medicare ID - Type Unspecified