MEDICARE: JONATHAN LEE D.D.S.

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	44919	CA

General Provider Information

NPI Number	:	1902121213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN LEE D.D.S.

Provider Business Mailing Address
First Line	:	2880 W OLYMPIC BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2644
Country	:	US
Telephone Number	:	213-487-2355
Fax Number	:

Provider Business Practice Location Address
First Line	:	2880 W OLYMPIC BLVD STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2644
Country	:	US
Telephone Number	:	213-487-2355
Fax Number	:

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

Provider Enumeration Date	:	03/30/2010
Last Update Date	:	03/30/2010

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