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General NPI Number Information
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NPI Number | 1043682412
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Entity Type | Organization
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Legal Business Name | DENTAL EXPRESS LLC
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Dates
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Enumeration Date | 10/26/2015
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Last Update Date | 10/26/2015
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Provider Practice Location Address
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Address Line | 1010 E UNIVERSITY DR BUILDING 2
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City | MESA
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State | AZ
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Zip | 85203-8055
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Country | US
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Telephone | 317-682-8247
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 E UNIVERSITY DR BUILDING 2
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City | MESA
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State | AZ
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Zip | 85203-8055
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Country | US
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Telephone | 317-682-8247
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUNGWOO LEE
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Credential | DDS
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Telephone | 317-682-8247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12010693A
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License Number State | AZ
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