Provider Demographics
NPI:1639617632
Name:MENIFEE ENDODONTICS
Entity Type:Organization
Organization Name:MENIFEE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAEHOON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:909-945-5262
Mailing Address - Street 1:27174 NEWPORT RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7384
Mailing Address - Country:US
Mailing Address - Phone:909-945-5262
Mailing Address - Fax:
Practice Address - Street 1:27174 NEWPORT RD STE 1
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-7384
Practice Address - Country:US
Practice Address - Phone:951-723-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUCAMONGA PEAK ENDODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548541223E0200X
CA632741223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376928481OtherENDODONTIST