Provider Demographics
NPI:1609277433
Name:ETHAN C. A LEE DENTAL INC.
Entity Type:Organization
Organization Name:ETHAN C. A LEE DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:CHUNG AN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-726-3204
Mailing Address - Street 1:6046 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022
Mailing Address - Country:US
Mailing Address - Phone:323-726-3204
Mailing Address - Fax:323-726-3390
Practice Address - Street 1:6046 WHITTIER BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022
Practice Address - Country:US
Practice Address - Phone:323-726-3204
Practice Address - Fax:323-726-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty