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General NPI Number Information
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NPI Number | 1851592950
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Entity Type | Organization
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Legal Business Name | C. JACK LEE, D.M.D., INC.
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 02/14/2008
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Provider Practice Location Address
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Address Line | 1321 N HARBOR BLVD SUITE 200
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City | FULLERTON
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State | CA
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Zip | 92835-4124
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Country | US
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Telephone | 714-871-8343
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Fax | 714-871-2338
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Provider Business Mailing Address
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Address Line | 1321 N HARBOR BLVD SUITE 200
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City | FULLERTON
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State | CA
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Zip | 92835-4124
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Country | US
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Telephone | 714-871-8343
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Fax | 714-871-2338
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Authorized Official
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Title or Position | OWNER
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Name | DR. C. JACK LEE
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Credential | D.M.D.
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Telephone | 714-871-8343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 45903
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License Number State | CA
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