=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093878308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BYUNG WOOK LEE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 08/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 S WESTERN AVE STE 101
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-4262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-766-0667
-----------------------------------------------------
Fax | 323-676-7488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 S WESTERN AVE STE 208
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-4270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-766-0667
-----------------------------------------------------
Fax | 323-676-7488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 41105
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------