Provider Demographics
NPI:1760565261
Name:LEE, CHAN Y (DDS)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:Y
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 S. VERMONT AVE. #205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006
Mailing Address - Country:US
Mailing Address - Phone:213-383-2466
Mailing Address - Fax:
Practice Address - Street 1:975 S. VERMONT AVE. #205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5906
Practice Address - Country:US
Practice Address - Phone:213-383-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA323451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice