Provider Demographics
NPI:1396054011
Name:LEE, KI BAEK (DDS)
Entity type:Individual
Prefix:
First Name:KI
Middle Name:BAEK
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 1:6501 EASTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-3003
Mailing Address - Country:US
Mailing Address - Phone:562-809-6177
Mailing Address - Fax:562-809-7659
Practice Address - Street 1:6501 EASTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-3003
Practice Address - Country:US
Practice Address - Phone:323-773-2082
Practice Address - Fax:323-560-3905
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice