Healthcare Provider Details

I. General information

NPI: 1124712526
Provider Name (Legal Business Name): SEONG EUN LEE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DANNY LEE DMD

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 07/12/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16944 S HIGHLAND AVE STE 400
FONTANA CA
92336-3467
US

IV. Provider business mailing address

3488 RIVERSIDE DR # 1
CHINO CA
91710-2956
US

V. Phone/Fax

Practice location:
  • Phone: 909-363-8036
  • Fax: 909-295-6673
Mailing address:
  • Phone: 217-553-3705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113284
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: