Provider Demographics
NPI:1588310015
Name:FORT BLISS FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:FORT BLISS FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:915-895-3678
Mailing Address - Street 1:11633 SAN VICENTE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6513
Mailing Address - Country:US
Mailing Address - Phone:915-895-3678
Mailing Address - Fax:
Practice Address - Street 1:1617 PLEASONTON RD.
Practice Address - Street 2:SUITE G129
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906
Practice Address - Country:US
Practice Address - Phone:915-895-3678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty