Basic Information
| Provider Information | |||||||||
| NPI: | 1407492218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAY K LEE DDS MD INC A PROFESSIONAL DENTAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 CENTURY PARK E STE 610 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900672009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108424811 | ||||||||
| FaxNumber: | 3102862177 | ||||||||
| Practice Location | |||||||||
| Address1: | 8700 BEVERLY BLVD | ||||||||
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| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104233277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2019 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3108424811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS, MD | ||||||||
| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.