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General NPI Number Information
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NPI Number | 1053868869
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Entity Type | Organization
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Legal Business Name | FORSYTH COUNTY PUBLIC HEALTH CLEVELAND AVE DENTAL CENTER
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Dates
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Enumeration Date | 09/09/2016
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Last Update Date | 09/09/2016
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Provider Practice Location Address
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Address Line | 501 N CLEVELAND AVE
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City | WINSTON SALEM
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State | NC
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Zip | 27101-4366
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Country | US
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Telephone | 336-703-3090
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Fax | 336-631-2340
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Provider Business Mailing Address
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Address Line | 501 N CLEVELAND AVE
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City | WINSTON SALEM
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State | NC
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Zip | 27101-4366
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Country | US
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Telephone | 336-703-3090
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Fax | 336-631-2340
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Authorized Official
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Title or Position | DENTIST
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Name | SUN MIN LEE
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Credential | DDS
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Telephone | 336-703-3090
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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 | 10063
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License Number State | NC
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