Provider Demographics
NPI:1528529278
Name:LEE, ALEXANDER
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 E SANTA CRUZ AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-5649
Mailing Address - Country:US
Mailing Address - Phone:408-480-3219
Mailing Address - Fax:
Practice Address - Street 1:13792 BEAR VALLEY RD STE 1
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-8713
Practice Address - Country:US
Practice Address - Phone:760-245-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1046921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty