Basic Information
| Provider Information | |||||||||
| NPI: | 1285995209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BADII LEE DENTAL CORPORATION, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SMILE WIDE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 NEWPORT BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495485588 | ||||||||
| FaxNumber: | 9495485731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 NEWPORT BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495485588 | ||||||||
| FaxNumber: | 9495485731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2012 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | HARVEY | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9495485588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS MDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.