MEDICARE: LEE MLK DENTAL GROUP, PC

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	:	1952497984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEE MLK DENTAL GROUP, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	3896 N MARTIN LUTHER KING BLVD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-6603
Country	:	US
Telephone Number	:	702-614-1792
Fax Number	:	702-933-0190

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHANNON K LEE
Credential	:	DMD
Telephone Number	:	702-614-1792

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	05/07/2015

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