Provider Demographics
NPI:1043682412
Name:DENTAL EXPRESS LLC
Entity type:Organization
Organization Name:DENTAL EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUNGWOO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-682-8247
Mailing Address - Street 1:1010 E UNIVERSITY DR
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8055
Mailing Address - Country:US
Mailing Address - Phone:317-682-8247
Mailing Address - Fax:
Practice Address - Street 1:1010 E UNIVERSITY DR
Practice Address - Street 2:BUILDING 2
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8055
Practice Address - Country:US
Practice Address - Phone:317-682-8247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12010693A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty