Provider Demographics
NPI:1477044345
Name:ETHAN C.A. LEE DENTAL INC.
Entity Type:Organization
Organization Name:ETHAN C.A. LEE DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:CA
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-458-3410
Mailing Address - Street 1:314 W. VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776
Mailing Address - Country:US
Mailing Address - Phone:626-458-3410
Mailing Address - Fax:626-458-3411
Practice Address - Street 1:314 W. VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776
Practice Address - Country:US
Practice Address - Phone:626-458-3410
Practice Address - Fax:626-458-3411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48688122300000X
CA485951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty