Provider Demographics
NPI:1902391816
Name:MILWAUKIE EMERGENCY DENTIST LLC
Entity Type:Organization
Organization Name:MILWAUKIE EMERGENCY DENTIST LLC
Other - Org Name:SUNRISE DENTAL OF MILWAUKIE
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BYUNG-IL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-305-6269
Mailing Address - Street 1:15595 SE PIONEER DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7323
Mailing Address - Country:US
Mailing Address - Phone:360-910-5802
Mailing Address - Fax:
Practice Address - Street 1:18807 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6735
Practice Address - Country:US
Practice Address - Phone:503-305-6269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9672261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental