Basic Information
| Provider Information | |||||||||
| NPI: | 1477074813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MOON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1141 FAIRVIEW AVE UNIT A | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910077047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264193713 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7540 ORANGETHORPE AVE STE A1 | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145762540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2017 | ||||||||
| LastUpdateDate: | 11/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 101511 | CA | N | Dental Providers | Dentist | General Practice | 122300000X | 101511 | CA | Y | Dental Providers | Dentist |
No ID Information.