FORM 1023-EZ for AMERICAN DENTAL MEDICINE INSTITUTE

Field Data
EIN 47-5299852
Case Number EO-2015331-000102
Form 1023-EZ version 62014
Eligibility Worksheet 1
Organization Name AMERICAN DENTAL MEDICINE INSTITUTE
Organization’s Mailing Address 4444 PEPPERWOOD AVE
City LONG BEACH
State CA
ZIP 90808
Accounting period End 12
Primary contact name WAN PENG
Primary contact phone [Hidden]
Primary contact phone extension [Hidden]
Primary contact fax [Hidden]
User fee submitted $400.00
Officer/Director/Trustee One

WAN PENG
PRESIDENT/DIRECTOR
4444 PEPPERWOOD AVE
LONG BEACH CA 90808

Officer/Director/Trustee Two

YUNZHANG LI
VICE PRESIDENT/DIRECTOR
4444 PEPPERWOOD AVE
LONG BEACH CA 90808

Officer/Director/Trustee Three

KAIRONG LI
TREASURER/DIRECTOR
4444 PEPPERWOOD AVE
LONG BEACH CA 90808

Organization’s website
Organization’s email JKSCLINIC@GMAIL.COM
Organization Incorporated Yes
Organization trust No
Necessary Organizing Documents Yes
Organization Incorporation Date 10/26/2015
Organization Incorporation State CA
Contains Limitation Yes
Does not expressly empower Yes
Contains dissolution Yes
National Taxonomy of Exempt Entities (NTEE) code P99 - Human Services - Multipurpose and Other N.E.C.
Organization’s purpose Charitable: Yes
Religious: No
Educational: No
Scientific: Yes
Literary: No
Public Safety: No
Amateur Sports: No
Cruelty Prevention: No
Qualify For Exemption No
Legislation influence No
Compensation of Officer director trustee No
Donation of funds No
Conducting Activities Outside of United States No
Financial transactions with officers No
Unrelated Gross Income $1,000 or More No
Gaming Activity No
Disaster relief assistance No
One Third Support Public No
One Third Support Gifts Yes
Benefit of College No
Private Foundation 508(e) No
Seeking Retroactive Reinstatement No
Seeking Section 7 Reinstatement No
Correctness Declaration Yes
Signature Name
Signature Title
Signature Date

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