MEDICARE: GUNDONG LEE DENTAL CORPORATION

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	65092	OTHER	CA	DENTAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1396308276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUNDONG LEE DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	16106 BELLFLOWER BLVD
Second Line	:
City	:	BELLFLOWER
State	:	CA
Zip	:	90706-4606
Country	:	US
Telephone Number	:	562-920-9220
Fax Number	:

Provider Business Practice Location Address
First Line	:	16106 BELLFLOWER BLVD
Second Line	:
City	:	BELLFLOWER
State	:	CA
Zip	:	90706-4606
Country	:	US
Telephone Number	:	562-920-9220
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. GUNDONG LEE
Credential	:	DDS
Telephone Number	:	909-800-1994

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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