Healthcare Provider Details

I. General information

NPI: 1952497984
Provider Name (Legal Business Name): LEE MLK DENTAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3896 N MARTIN LUTHER KING BLVD
N LAS VEGAS NV
89032-6603
US

IV. Provider business mailing address

17000 RED HILL AVE
IRVINE CA
92614-5626
US

V. Phone/Fax

Practice location:
  • Phone: 702-614-1792
  • Fax: 702-933-0190
Mailing address:
  • Phone: 714-845-8890
  • Fax: 949-474-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANNON K LEE
Title or Position: OWNER
Credential: DMD
Phone: 702-614-1792