Provider Demographics
NPI:1821654831
Name:SANGEUN LEE DENTAL PRACTICE
Entity Type:Organization
Organization Name:SANGEUN LEE DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANGEUN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-851-7323
Mailing Address - Street 1:25441 HURON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3610
Mailing Address - Country:US
Mailing Address - Phone:909-851-7323
Mailing Address - Fax:
Practice Address - Street 1:1265 N LA CADENA DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2418
Practice Address - Country:US
Practice Address - Phone:909-851-7323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental