Basic Information
| Provider Information | |||||||||
| NPI: | 1003006529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOON | ||||||||
| MiddleName: | SEUNG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 OLD PALISADE RD APT 3201 | ||||||||
| Address2: | |||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070247025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9172042333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7523 FORT HAMILTON PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112282305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182384133 | ||||||||
| FaxNumber: | 7182389843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 050790 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02722636 | 05 | NY | MEDICAID |