1023408507 NPI number — BADII LEE DENTAL CORPORATION, INC.

Table of content: (NPI 1023408507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023408507 NPI number — BADII LEE DENTAL CORPORATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BADII LEE DENTAL CORPORATION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SMILE WIDE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023408507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19762 MACARTHUR BLVD.
Provider Second Line Business Mailing Address:
100
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92612-8275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-596-8100
Provider Business Mailing Address Fax Number:
562-424-9807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3325 PALO VERDE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90808-4132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-429-1642
Provider Business Practice Location Address Fax Number:
562-429-1643
Provider Enumeration Date:
02/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
HARVEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-596-8100

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  56861 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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