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General NPI Number Information
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NPI Number | 1902391816
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Entity Type | Organization
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Legal Business Name | MILWAUKIE EMERGENCY DENTIST LLC
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Dates
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Enumeration Date | 06/25/2018
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Last Update Date | 06/25/2018
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Provider Practice Location Address
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Address Line | 18807 SE MCLOUGHLIN BLVD
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City | MILWAUKIE
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State | OR
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Zip | 97267-6735
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Country | US
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Telephone | 503-305-6269
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Fax |
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Provider Business Mailing Address
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Address Line | 15595 SE PIONEER DR
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City | CLACKAMAS
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State | OR
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Zip | 97015-7323
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Country | US
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Telephone | 360-910-5802
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. BYUNG-IL LEE
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Credential | DMD
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Telephone | 503-305-6269
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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 | D9672
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License Number State | OR
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