Healthcare Provider Details

I. General information

NPI: 1255064614
Provider Name (Legal Business Name): KENNETH LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 W 63RD ST
CHICAGO IL
60629-3325
US

IV. Provider business mailing address

2 BAY CLUB DR APT 16K
BAYSIDE NY
11360-2930
US

V. Phone/Fax

Practice location:
  • Phone: 773-776-8300
  • Fax:
Mailing address:
  • Phone: 347-551-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033918
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: