=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043764293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNG KYU LEE DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2016
-----------------------------------------------------
Last Update Date | 01/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2125 S BREA CANYON RD
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-308-1188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2125 S BREA CANYON RD
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-308-1188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SUNG KYU LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 213-308-1188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 61684
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------