Healthcare Provider Details

I. General information

NPI: 1487059010
Provider Name (Legal Business Name): KENENTH K. LEE, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 E. ANAHEIM ST.
LONG BEACH CA
90804
US

IV. Provider business mailing address

4755 E ANAHEIM ST
LONG BEACH CA
90804-3123
US

V. Phone/Fax

Practice location:
  • Phone: 562-494-5060
  • Fax:
Mailing address:
  • Phone: 562-494-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40652
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number40652
License Number StateCA

VIII. Authorized Official

Name: SOKVY NGONG
Title or Position: OFFICE MANAGER
Credential:
Phone: 562-494-5060