Provider Demographics
NPI:1699452821
Name:KI LEE DENTAL CORP.
Entity type:Organization
Organization Name:KI LEE DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:BAEK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-880-3704
Mailing Address - Street 1:11900 SOUTH ST STE 122
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6800
Mailing Address - Country:US
Mailing Address - Phone:562-809-6177
Mailing Address - Fax:562-809-7659
Practice Address - Street 1:11900 SOUTH ST STE 122
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6800
Practice Address - Country:US
Practice Address - Phone:562-809-6177
Practice Address - Fax:562-809-7659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KI BAEK LEE DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-29
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508373002Medicaid