Healthcare Provider Details

I. General information

NPI: 1831261866
Provider Name (Legal Business Name): YOUNGSYL OH LEE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 LAKE TAHOE BLVD. STE #5
S. LAKE TAHOE CA
96150-6409
US

IV. Provider business mailing address

2180 LAKE TAHOE BLVD. STE #5
S. LAKE TAHOE CA
96150-7916
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-8229
  • Fax: 530-541-8964
Mailing address:
  • Phone: 530-541-8229
  • Fax: 530-541-8964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44418
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4898T
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: