1417286303 NPI number — BADII LEE DENTAL CORPORATION, INC

Table of content: (NPI 1417286303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417286303 NPI number — BADII LEE DENTAL CORPORATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BADII LEE DENTAL CORPORATION, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SMILE WIDE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417286303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22330 HAWTHORNE BLVD.
Provider Second Line Business Mailing Address:
SUITE 2016
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-375-5801
Provider Business Mailing Address Fax Number:
310-375-6071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22330 HAWTHORNE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 2016
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-375-5801
Provider Business Practice Location Address Fax Number:
310-375-6071
Provider Enumeration Date:
12/23/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BADII
Authorized Official First Name:
KIAVASH
Authorized Official Middle Name:
KEVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-835-2383

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 54538 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)