Provider Demographics
NPI:1902121213
Name:LEE, JONATHAN (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 W OLYMPIC BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2644
Mailing Address - Country:US
Mailing Address - Phone:213-487-2355
Mailing Address - Fax:
Practice Address - Street 1:2880 W OLYMPIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2644
Practice Address - Country:US
Practice Address - Phone:213-487-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA449191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice