Basic Information
| Provider Information | |||||||||
| NPI: | 1205089190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4651 WINTHROP DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926496417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142224551 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 E DEL AMO BLVD | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907463314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105155672 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 56016 | CA | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | 56016 | 01 | CA | STATE LICENSE | OTHER |