Provider Demographics
NPI:1861182214
Name:LEE, JARRAD (BSDH, RDA, RDH)
Entity type:Individual
Prefix:
First Name:JARRAD
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:BSDH, RDA, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11612 SOLAIRE WAY
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-7227
Mailing Address - Country:US
Mailing Address - Phone:310-621-3424
Mailing Address - Fax:
Practice Address - Street 1:795 E 2ND ST FL 3
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-706-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33483124Q00000X
CA86792126800000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No124Q00000XDental ProvidersDental Hygienist
No126800000XDental ProvidersDental Assistant