Basic Information
| Provider Information | |||||||||
| NPI: | 1487062816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD STE 610 | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477011457 | ||||||||
| FaxNumber: | 8474967603 | ||||||||
| Practice Location | |||||||||
| Address1: | 25248 PACIFIC HWY S STE 105 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980326530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539465766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60768358 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1487062816 | 05 | IL | MEDICAID |