=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467642678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOO NAM LEE DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2007
-----------------------------------------------------
Last Update Date | 07/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3818 N PECK ROAD SUITE C
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-350-0944
-----------------------------------------------------
Fax | 626-350-9133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3818 N PECK ROAD SUITE C
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-350-0944
-----------------------------------------------------
Fax | 626-350-9133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SOO NAM LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 626-350-0944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 27786
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------