Provider Demographics
NPI:1215248729
Name:LEE GHORBANIAN ILTD
Entity type:Organization
Organization Name:LEE GHORBANIAN ILTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-644-1126
Mailing Address - Street 1:12755 SW 2ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005
Mailing Address - Country:US
Mailing Address - Phone:503-641-4207
Mailing Address - Fax:503-644-0692
Practice Address - Street 1:12755 SW 2ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-641-4207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty