Provider Demographics
NPI:1184054058
Name:LEE, GRACE EUNAH
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:EUNAH
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EUN-AH
Other - Middle Name:
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:11016 VIA DEL CORSO
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-2384
Mailing Address - Country:US
Mailing Address - Phone:909-528-7824
Mailing Address - Fax:
Practice Address - Street 1:11016 VIA DEL CORSO
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2384
Practice Address - Country:US
Practice Address - Phone:951-729-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist