Healthcare Provider Details

I. General information

NPI: 1184766677
Provider Name (Legal Business Name): BEOM MO LEE DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 S WESTERN AVE 207
LOS ANGELES CA
90006
US

IV. Provider business mailing address

966 S WESTERN AVE 207
LOS ANGELES CA
90006
US

V. Phone/Fax

Practice location:
  • Phone: 323-734-2117
  • Fax: 323-734-2117
Mailing address:
  • Phone: 323-734-2117
  • Fax: 323-734-2117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number46284
License Number StateCA

VIII. Authorized Official

Name: BEOM MO LEE
Title or Position: PRESIDENT
Credential: DDS PHD
Phone: 323-734-3710