MEDICARE: KANG K. LEE,DDS,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
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477650125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANG K. LEE,DDS,INC.

Provider Business Mailing Address
First Line	:	14435 HAMLIN ST
Second Line	:	SUITE 205
City	:	VAN NUYS
State	:	CA
Zip	:	91401-6205
Country	:	US
Telephone Number	:	818-997-6300
Fax Number	:	818-997-6335

Provider Business Practice Location Address
First Line	:	14435 HAMLIN ST
Second Line	:	SUITE 205
City	:	VAN NUYS
State	:	CA
Zip	:	91401-6205
Country	:	US
Telephone Number	:	818-997-6300
Fax Number	:	818-997-6335

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KANG KU LEE
Credential	:	D.D.S.
Telephone Number	:	818-997-6300

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	08/22/2020

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