Healthcare Provider Details

I. General information

NPI: 1033474770
Provider Name (Legal Business Name): KIHO LEE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE CHS 20-140
LOS ANGELES CA
90095-1668
US

IV. Provider business mailing address

10833 LE CONTE AVE CHS 20-140
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-4705
  • Fax:
Mailing address:
  • Phone: 310-825-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number60785
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberWADE6014957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: