Provider Demographics
NPI:1104088160
Name:GOTTSCHALK AND LEE DENTAL CORP.
Entity type:Organization
Organization Name:GOTTSCHALK AND LEE DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:KIANFU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-344-4210
Mailing Address - Street 1:5620 WILBUR AVE. SUITE 319
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1351
Mailing Address - Country:US
Mailing Address - Phone:818-344-4210
Mailing Address - Fax:818-344-4093
Practice Address - Street 1:5620 WILBUR AVE. SUITE 319
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1351
Practice Address - Country:US
Practice Address - Phone:818-344-4210
Practice Address - Fax:818-344-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUR01353F261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental