Healthcare Provider Details

I. General information

NPI: 1740739374
Provider Name (Legal Business Name): LQKT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16040 HARBOR BLVD STE F
FOUNTAIN VALLEY CA
92708-1327
US

IV. Provider business mailing address

16040 HARBOR BLVD STE F
FOUNTAIN VALLEY CA
92708-1327
US

V. Phone/Fax

Practice location:
  • Phone: 714-000-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number44916
License Number StateCA

VIII. Authorized Official

Name: KIM QUOC LE
Title or Position: OWNER
Credential: D.D.S
Phone: 714-000-0000