Provider Demographics
NPI:1760611958
Name:LEE, HEA CHAN (LD)
Entity Type:Individual
Prefix:
First Name:HEA CHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 SW 185TH AVE
Mailing Address - Street 2:220
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-1567
Mailing Address - Country:US
Mailing Address - Phone:503-746-4770
Mailing Address - Fax:503-746-4915
Practice Address - Street 1:4055 SW 185TH AVE
Practice Address - Street 2:220
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97007
Practice Address - Country:US
Practice Address - Phone:503-746-4770
Practice Address - Fax:503-746-4915
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTD010126667122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist