Provider Demographics
NPI:1639216245
Name:LEE, MI-A (DMD)
Entity Type:Individual
Prefix:
First Name:MI-A
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S HOPE ST APT 609
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-5020
Mailing Address - Country:US
Mailing Address - Phone:310-329-7600
Mailing Address - Fax:310-329-7647
Practice Address - Street 1:15435 S WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4331
Practice Address - Country:US
Practice Address - Phone:310-329-7600
Practice Address - Fax:310-329-7647
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist