Provider Demographics
NPI:1568929461
Name:LEE, SUE
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-5920
Mailing Address - Country:US
Mailing Address - Phone:646-789-3633
Mailing Address - Fax:
Practice Address - Street 1:2771 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5750
Practice Address - Country:US
Practice Address - Phone:323-835-6123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2021-07-20
Deactivation Date:2019-02-27
Deactivation Code:
Reactivation Date:2019-06-14
Provider Licenses
StateLicense IDTaxonomies
NY0612091223G0001X
390200000X
CA1062061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program