Provider Demographics
NPI:1790281202
Name:LEE, CRYSTAL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 ACAMAR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1054
Mailing Address - Country:US
Mailing Address - Phone:909-815-8826
Mailing Address - Fax:
Practice Address - Street 1:903 CALLE AMANECER STE 110
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6253
Practice Address - Country:US
Practice Address - Phone:949-361-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice