Provider Demographics
NPI:1891942744
Name:LEE, CHARLES PETERS (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PETERS
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TSAITEIK
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:11092 ANDERSON STREET
Mailing Address - Street 2:LLU SCHOOL OF DENTISTRY
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350
Mailing Address - Country:US
Mailing Address - Phone:909-558-4613
Mailing Address - Fax:909-558-4192
Practice Address - Street 1:11092 ANDERSON STREET
Practice Address - Street 2:LLU SCHOOL OF DENTISTRY
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350
Practice Address - Country:US
Practice Address - Phone:909-558-4613
Practice Address - Fax:909-558-4192
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25930OtherSTATE LICENSE