=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609163849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTHER EUNSUN LEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2011
-----------------------------------------------------
Last Update Date | 04/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2655 W OLYMPIC BLVD STE 206
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-385-4011
-----------------------------------------------------
Fax | 213-947-4623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2655 W OLYMPIC BLVD STE 206
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-385-4011
-----------------------------------------------------
Fax | 213-947-4623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ESTHER EUNSUN LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 213-210-3920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 55927
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------