1235754334 NPI number — SUSAN J. LEE, DMD, MD INC

Table of content: (NPI 1235754334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235754334 NPI number — SUSAN J. LEE, DMD, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN J. LEE, DMD, MD 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:
Provider Other Organization Name Type Code:
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:
1235754334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11851 LAURELWOOD DR APT 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUDIO CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91604-4928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-939-4378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 N PENNSYLVANIA AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91741-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-852-0365
Provider Business Practice Location Address Fax Number:
626-852-0369
Provider Enumeration Date:
06/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-939-4378

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14457151 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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