Provider Demographics
NPI:1245518307
Name:LEE, KEIJIN JENNY (DDS)
Entity type:Individual
Prefix:DR
First Name:KEIJIN
Middle Name:JENNY
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11864 HOLLIS CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6754
Mailing Address - Country:US
Mailing Address - Phone:909-230-0090
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1706
Practice Address - Country:US
Practice Address - Phone:909-558-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist