Provider Demographics
NPI:1912052978
Name:JASON S LEE DDS INC
Entity Type:Organization
Organization Name:JASON S LEE DDS INC
Other - Org Name:SIGNATURE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-910-8282
Mailing Address - Street 1:1183 E FOOTHILL BLVD
Mailing Address - Street 2:UNIT 240
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4049
Mailing Address - Country:US
Mailing Address - Phone:909-981-6882
Mailing Address - Fax:909-981-0276
Practice Address - Street 1:1183 E FOOTHILL BLVD
Practice Address - Street 2:UNIT 240
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4049
Practice Address - Country:US
Practice Address - Phone:909-981-6882
Practice Address - Fax:909-981-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98378-01OtherDELTA HEALTHY FAMILY
CA01604010OtherUNITED CONCORDIA NUMBER
CA247386OtherDELTA DENTAL # FOR UPLAND
CAG93055-01Medicaid