Healthcare Provider Details

I. General information

NPI: 1871403006
Provider Name (Legal Business Name): DONG SUP LEE DMD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26640 WESTERN AVE STE I
HARBOR CITY CA
90710-3659
US

IV. Provider business mailing address

446 W CENTRAL AVE
BREA CA
92821
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-8111
  • Fax:
Mailing address:
  • Phone: 804-928-4695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DONG SUP LEE
Title or Position: PRESIDENT
Credential: DMD
Phone: 804-928-4695