Healthcare Provider Details

I. General information

NPI: 1609293406
Provider Name (Legal Business Name): CHRISTINE JAE EUN LEE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST STE A205
COSTA MESA CA
92626-5951
US

IV. Provider business mailing address

4842 CORSICA DR
CYPRESS CA
90630-3576
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-0484
  • Fax:
Mailing address:
  • Phone: 619-325-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number64272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: