=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053508440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON SANG LEE DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2007
-----------------------------------------------------
Last Update Date | 09/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 E FRUIT ST SUITE 206
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-4479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-547-7379
-----------------------------------------------------
Fax | 714-547-1202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 E FRUIT ST SUITE 206
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-4479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-547-7379
-----------------------------------------------------
Fax | 714-547-1202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JASON LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-547-7379
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 47386
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------