Provider Demographics
NPI:1861603573
Name:LEE, KWANG BACK (DDS)
Entity type:Individual
Prefix:DR
First Name:KWANG
Middle Name:BACK
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 JASMINE PARKE DR
Mailing Address - Street 2:#2
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-2287
Mailing Address - Country:US
Mailing Address - Phone:213-718-2926
Mailing Address - Fax:
Practice Address - Street 1:4015 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3401
Practice Address - Country:US
Practice Address - Phone:213-385-1325
Practice Address - Fax:213-380-9842
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist