MEDICARE: DR. SEONG SUK LEE DDS

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
1	1223G0001X	General Practice Dentistry	41941	CA

General Provider Information

NPI Number	:	1356456966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SEONG SUK LEE DDS

Provider Business Mailing Address
First Line	:	4627 SANTA MONICA BLVD STE D
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1831
Country	:	US
Telephone Number	:	323-644-0260
Fax Number	:	323-644-0114

Provider Business Practice Location Address
First Line	:	4627 SANTA MONICA BLVD STE D
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1831
Country	:	US
Telephone Number	:	323-644-0260
Fax Number	:	323-644-0114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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