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NPI Code Detail

MEDICARE: KWANG LEE D.D.S. INC.

MEDICARE: KWANG LEE D.D.S. INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistCA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11223G0001XOTHERTAXANOMY

General Provider Information

NPI Number : 1154709442
Entity Type Code : Organization
Provider Name (Legal Business Name) : KWANG LEE D.D.S. INC.
Provider Business Mailing Address
First Line : 1558 W GRAND AVE
Second Line :
City : GROVER BEACH
State : CA
Zip : 93433-2236
Country : US
Telephone Number : 805-489-8904
Fax Number : 805-474-5899
Provider Business Practice Location Address
First Line : 1558 W GRAND AVE
Second Line :
City : GROVER BEACH
State : CA
Zip : 93433-2236
Country : US
Telephone Number : 805-489-8904
Fax Number : 805-474-5899
Authorized Official
Title or Position : DENTIST
Name : KWANG LEE
Credential : DDS
Telephone Number : 805-489-8904
Provider Enumeration Date : 05/07/2015
Last Update Date : 05/08/2015

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