Provider Demographics
NPI:1356580963
Name:LEE, MELISSA KIM (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:KIM
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N KENWOOD ST APT 206
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-5406
Mailing Address - Country:US
Mailing Address - Phone:818-653-7489
Mailing Address - Fax:
Practice Address - Street 1:345 N KENWOOD ST APT 206
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-5406
Practice Address - Country:US
Practice Address - Phone:818-653-7489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA580421223X0400X
TX252031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25203OtherSTATE BOARD OF DENTAL EXAMINERS
CA58042OtherSTATE LICENSE