Healthcare Provider Details

I. General information

NPI: 1013305689
Provider Name (Legal Business Name): MASON Y. LEE, DDS, A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 LAS GALLINAS AVE STE 207
SAN RAFAEL CA
94903-3432
US

IV. Provider business mailing address

750 LAS GALLINAS AVE STE 207
SAN RAFAEL CA
94903-3432
US

V. Phone/Fax

Practice location:
  • Phone: 415-472-5040
  • Fax: 415-472-5043
Mailing address:
  • Phone: 415-472-5040
  • Fax: 415-472-5043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number42929
License Number StateCA

VIII. Authorized Official

Name: DR. MASON Y LEE
Title or Position: PRESIDENT
Credential: DDS, MD
Phone: 415-472-5040