Healthcare Provider Details

I. General information

NPI: 1639617632
Provider Name (Legal Business Name): MENIFEE ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

27174 NEWPORT RD STE 1
MENIFEE CA
92584-7384
US

IV. Provider business mailing address

27174 NEWPORT RD STE 1
MENIFEE CA
92584-7384
US

V. Phone/Fax

Practice location:
  • Phone: 951-723-8801
  • Fax:
Mailing address:
  • Phone: 909-945-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number54854
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number63274
License Number StateCA

VIII. Authorized Official

Name: JAEHOON LEE
Title or Position: ENDODONTIST
Credential: DMD
Phone: 909-945-5262