Basic Information
| Provider Information | |||||||||
| NPI: | 1386034247 | ||||||||
| 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: | 19762 MACARTHUR BLVD. | ||||||||
| Address2: | 100 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926127209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495968100 | ||||||||
| FaxNumber: | 5624249807 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908063051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625950731 | ||||||||
| FaxNumber: | 5625956462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2015 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | HARVEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9495968100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 56861 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.