Healthcare Provider Details

I. General information

NPI: 1811140536
Provider Name (Legal Business Name): LC MEDICAL & DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2008
Last Update Date: 10/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 LINCOLN AVE SUITE H
BUENA PARK CA
90620-3463
US

IV. Provider business mailing address

5825 LINCOLN AVE SUITE H
BUENA PARK CA
90620-3463
US

V. Phone/Fax

Practice location:
  • Phone: 714-761-1736
  • Fax: 714-761-7179
Mailing address:
  • Phone: 714-761-1736
  • Fax: 714-761-7179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number49290
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA61531
License Number StateCA

VIII. Authorized Official

Name: CHRISTINE CHIEM
Title or Position: SECRETARY
Credential: DDS
Phone: 714-761-1736