Provider Demographics
NPI:1386783736
Name:LEE, GANNON KA (DDS)
Entity type:Individual
Prefix:DR
First Name:GANNON
Middle Name:KA
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26302 LA PAZ RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5313
Mailing Address - Country:US
Mailing Address - Phone:949-380-0315
Mailing Address - Fax:949-380-7830
Practice Address - Street 1:26302 LA PAZ RD
Practice Address - Street 2:SUITE 210
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5313
Practice Address - Country:US
Practice Address - Phone:949-380-0315
Practice Address - Fax:949-380-7830
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice