Provider Demographics
NPI:1528410123
Name:DR SAMUEL LEE DENTAL CORP
Entity Type:Organization
Organization Name:DR SAMUEL LEE DENTAL CORP
Other - Org Name:INTERNATIONAL ACADEMY OF DENTAL IMPLANT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS DMSC
Authorized Official - Phone:714-718-3446
Mailing Address - Street 1:6727 FLANDERS DRIVE #220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121
Mailing Address - Country:US
Mailing Address - Phone:858-229-9869
Mailing Address - Fax:
Practice Address - Street 1:6727 FLANDERS DR STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2926
Practice Address - Country:US
Practice Address - Phone:858-229-9869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58462122300000X
CA513531223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty