MEDICARE: SAN FERNANDO FAMILY DENTAL GROUP

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

General Provider Information

NPI Number	:	1912864760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN FERNANDO FAMILY DENTAL GROUP

Provider Business Mailing Address
First Line	:	3129 N SAN FERNANDO RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-1412
Country	:	US
Telephone Number	:	323-257-7744
Fax Number	:	323-257-5430

Provider Business Practice Location Address
First Line	:	3129 N SAN FERNANDO RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-1412
Country	:	US
Telephone Number	:	323-257-7744
Fax Number	:	323-257-5430

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CHANG WOO LEE
Credential	:
Telephone Number	:	323-257-7744

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	02/17/2026

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