Provider Demographics
NPI:1821400763
Name:IBARRA, LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:IBARRA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25460 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5966
Mailing Address - Country:US
Mailing Address - Phone:951-677-1054
Mailing Address - Fax:
Practice Address - Street 1:25460 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5966
Practice Address - Country:US
Practice Address - Phone:951-677-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65106122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program