Basic Information
| Provider Information | |||||||||
| NPI: | 1134417603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BADII LEE DENTAL CORPORATION, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SMILE WIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14370 CULVER DR STE A | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926040319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495516555 | ||||||||
| FaxNumber: | 9495516556 | ||||||||
| Practice Location | |||||||||
| Address1: | 14370 CULVER DR STE A | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926040319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495516555 | ||||||||
| FaxNumber: | 9495516556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | BADII | ||||||||
| AuthorizedOfficialFirstName: | KIAVASH | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7148352383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 54538 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223X0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.