=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902766488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BBDC DENTAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2025
-----------------------------------------------------
Last Update Date | 11/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 663 WESTWOOD AVE STE B
-----------------------------------------------------
City | RIVER VALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-6294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-557-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 663 WESTWOOD AVE STE B
-----------------------------------------------------
City | RIVER VALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-6294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KIWON LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-557-8007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------