Healthcare Provider Details

I. General information

NPI: 1750855995
Provider Name (Legal Business Name): BRIAN LEE, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18832 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-7304
US

IV. Provider business mailing address

18832 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-7304
US

V. Phone/Fax

Practice location:
  • Phone: 714-964-0036
  • Fax: 714-964-5336
Mailing address:
  • Phone: 714-964-0036
  • Fax: 714-964-5336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN LEE
Title or Position: CEO
Credential: DDS
Phone: 714-964-0036