MEDICARE: DR. KANG KU LEE D.D.S.

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	1223G0001X	General Practice Dentistry	33322	CA

General Provider Information

NPI Number	:	1912004250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KANG KU LEE D.D.S.

Provider Business Mailing Address
First Line	:	14435 HAMLIN ST
Second Line	:	SUITE 205
City	:	VAN NUYS
State	:	CA
Zip	:	91401-6205
Country	:	US
Telephone Number	:	818-997-6300
Fax Number	:	818-997-6335

Provider Business Practice Location Address
First Line	:	14435 HAMLIN ST
Second Line	:	SUITE 205
City	:	VAN NUYS
State	:	CA
Zip	:	91401-6205
Country	:	US
Telephone Number	:	818-997-6300
Fax Number	:	818-997-6335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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