Provider Demographics
NPI:1174744569
Name:JIN IL T. LEE, D.D.S., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JIN IL T. LEE, D.D.S., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIN IL
Authorized Official - Middle Name:TAEK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-644-0600
Mailing Address - Street 1:1752 S VICTORIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6192
Mailing Address - Country:US
Mailing Address - Phone:805-644-0600
Mailing Address - Fax:805-644-0611
Practice Address - Street 1:1752 S VICTORIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6192
Practice Address - Country:US
Practice Address - Phone:805-644-0600
Practice Address - Fax:805-644-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1511172Medicare UPIN