Provider Demographics
NPI:1235754334
Name:SUSAN J. LEE, DMD, MD INC
Entity Type:Organization
Organization Name:SUSAN J. LEE, DMD, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-939-4378
Mailing Address - Street 1:11851 LAURELWOOD DR APT 103
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-4928
Mailing Address - Country:US
Mailing Address - Phone:818-939-4378
Mailing Address - Fax:
Practice Address - Street 1:175 N PENNSYLVANIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3316
Practice Address - Country:US
Practice Address - Phone:626-852-0365
Practice Address - Fax:626-852-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14457151OtherCAQH