Provider Demographics
NPI:1578790465
Name:LEE, DIANA C
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:C
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 1:991 PINE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4599
Mailing Address - Country:US
Mailing Address - Phone:213-519-6226
Mailing Address - Fax:
Practice Address - Street 1:991 PINE AVE APT 2
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4599
Practice Address - Country:US
Practice Address - Phone:213-519-6226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA583421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice