=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184151045
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZA LEE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2017
-----------------------------------------------------
Last Update Date | 12/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1746 NOGALES ST
-----------------------------------------------------
City | ROWLAND HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-913-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1616 RANGE CT
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-4318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-637-8341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 104496
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------