Provider Demographics
NPI:1700229952
Name:M.K.LE PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:M.K.LE PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAI
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-849-7649
Mailing Address - Street 1:570 MASONIC WAY
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2703
Mailing Address - Country:US
Mailing Address - Phone:650-517-3328
Mailing Address - Fax:408-928-5673
Practice Address - Street 1:570 MASONIC WAY
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2703
Practice Address - Country:US
Practice Address - Phone:650-517-3328
Practice Address - Fax:408-928-5673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty