Provider Demographics
NPI:1003536251
Name:LEE, YONGJAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:YONGJAE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16963 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5420
Mailing Address - Country:US
Mailing Address - Phone:213-352-1166
Mailing Address - Fax:
Practice Address - Street 1:900 S WESTMORELAND AVE STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5671
Practice Address - Country:US
Practice Address - Phone:213-352-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107879122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist