Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 40976 | CA |
NPI | 1003037813 |
---|---|
Provider Name | Tina Mieun Park-Lee |
First Address | Loma Linda, CA 92354-6732 |
Second Address | Loma Linda, CA 92354-6732 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2007 |
Last Update Date | 12/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C3701431 | DRIVER LISCENCE (01) | CA |