=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932672656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOMI LEE DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2019
-----------------------------------------------------
Last Update Date | 01/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 E WASHINGTON ST
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-3210
-----------------------------------------------------
Fax | 909-512-6897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 E WASHINGTON ST
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-3210
-----------------------------------------------------
Fax | 909-512-6897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NOMI LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-825-3210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------