Healthcare Provider Details

I. General information

NPI: 1376928481
Provider Name (Legal Business Name): CUCAMONGA PEAK ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11438 KENYON WAY # 3-C
RANCHO CUCAMONGA CA
91701-9230
US

IV. Provider business mailing address

11438 KENYON WAY # 3-C
RANCHO CUCAMONGA CA
91701-9230
US

V. Phone/Fax

Practice location:
  • Phone: 909-945-5262
  • Fax: 909-945-5223
Mailing address:
  • Phone: 909-945-5262
  • Fax: 909-945-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number63274
License Number StateCA

VIII. Authorized Official

Name: DR. JAEHOON LEE
Title or Position: OWNER
Credential: DMD
Phone: 909-945-5262