Provider Demographics
NPI:1851592950
Name:C. JACK LEE, D.M.D., INC.
Entity Type:Organization
Organization Name:C. JACK LEE, D.M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C.
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:714-871-8343
Mailing Address - Street 1:1321 N HARBOR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4124
Mailing Address - Country:US
Mailing Address - Phone:714-871-8343
Mailing Address - Fax:714-871-2338
Practice Address - Street 1:1321 N HARBOR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4124
Practice Address - Country:US
Practice Address - Phone:714-871-8343
Practice Address - Fax:714-871-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45903261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental