Provider Demographics
NPI: | 1952497984 |
---|---|
Name: | LEE MLK DENTAL GROUP, PC |
Entity Type: | Organization |
Organization Name: | LEE MLK DENTAL GROUP, PC |
Other - Org Name: | ALEXANDER DENTAL GROUP AND ORTHODONTICS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SHANNON |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 702-614-1792 |
Mailing Address - Street 1: | 17000 RED HILL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | IRVINE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92614-5626 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-845-8890 |
Mailing Address - Fax: | 949-474-1495 |
Practice Address - Street 1: | 3896 N MARTIN LUTHER KING BLVD |
Practice Address - Street 2: | |
Practice Address - City: | N LAS VEGAS |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89032-6603 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-614-1792 |
Practice Address - Fax: | 702-933-0190 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-10-05 |
Last Update Date: | 2015-05-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |