Provider Demographics
NPI:1518985886
Name:LEE, JACK I (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:I
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 1:3030 MADERO CT
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-4204
Mailing Address - Country:US
Mailing Address - Phone:626-348-9307
Mailing Address - Fax:
Practice Address - Street 1:961 N MILLIKEN AVE STE 103
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5022
Practice Address - Country:US
Practice Address - Phone:909-581-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982293853OtherALEX SOLEIMANI