Basic Information
| Provider Information | |||||||||
| NPI: | 1316253776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEE&LEE HIRAM CLARK PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CROWN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10260 WESTHEIMER RD | ||||||||
| Address2: | STE 390 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770423110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139775300 | ||||||||
| FaxNumber: | 7139775348 | ||||||||
| Practice Location | |||||||||
| Address1: | 4407 W FUQUA ST # R | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770456256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134347333 | ||||||||
| FaxNumber: | 7134347334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7139775300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 177045501 | 05 | TX | MEDICAID |