Provider Demographics
NPI:1689120149
Name:KEUN CHAN LEE DDS INC
Entity Type:Organization
Organization Name:KEUN CHAN LEE DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCERO
Authorized Official - Middle Name:
Authorized Official - Last Name:DUVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-924-2448
Mailing Address - Street 1:12531 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-1607
Mailing Address - Country:US
Mailing Address - Phone:562-924-2448
Mailing Address - Fax:562-402-7587
Practice Address - Street 1:12531 CARSON ST
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-1607
Practice Address - Country:US
Practice Address - Phone:562-924-2448
Practice Address - Fax:562-402-7587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEUN CHAN LEE DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty