Basic Information
Provider Information | |||||||||
NPI: | 1578845277 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | WOONG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 W COMMONWEALTH AVE APT 237 | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928333019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155889617 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 20700 AVALON BLVD STE 600 | ||||||||
Address2: |   | ||||||||
City: | CARSON | ||||||||
State: | CA | ||||||||
PostalCode: | 907463701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3102416175 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2011 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 27448 | TX | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | 101202 | CA | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.