MEDICARE: DENTAL GROUP OF SUNG Y LEE DMD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1326738287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL GROUP OF SUNG Y LEE DMD INC

Provider Business Mailing Address
First Line	:	3174 E GAGE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-5346
Country	:	US
Telephone Number	:	323-581-3011
Fax Number	:	323-581-3011

Provider Business Practice Location Address
First Line	:	3174 E GAGE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-5346
Country	:	US
Telephone Number	:	323-581-3011
Fax Number	:	323-581-3011

Authorized Official
Title or Position	:	CEO
Name	:	SUNG LEE
Credential	:	DMD
Telephone Number	:	310-787-1233

Provider Enumeration Date	:	05/12/2023
Last Update Date	:	12/19/2023

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