Provider Demographics
NPI:1528579273
Name:KIWON LEE, D.D.S., PC
Entity Type:Organization
Organization Name:KIWON LEE, D.D.S., PC
Other - Org Name:BEAR BROOK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ASSISITANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-229-1441
Mailing Address - Street 1:305 W GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1813
Mailing Address - Country:US
Mailing Address - Phone:201-746-9474
Mailing Address - Fax:
Practice Address - Street 1:305 W GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1813
Practice Address - Country:US
Practice Address - Phone:201-746-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-21
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty