=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174677009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHIA LEE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 11/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20071 STATE ROUTE 410 E
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-8460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-862-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20071 STATE ROUTE 410 E
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-5540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-862-1015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 51611
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE 60200022
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------