Provider Demographics
NPI:1477074813
Name:LEE, SUSAN MOON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MOON
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 FAIRVIEW AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7047
Mailing Address - Country:US
Mailing Address - Phone:626-419-3713
Mailing Address - Fax:
Practice Address - Street 1:7540 ORANGETHORPE AVE STE A1
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621
Practice Address - Country:US
Practice Address - Phone:714-576-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1015111223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice