Provider Demographics
NPI:1033131297
Name:LEE, SOO S (DMD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:S
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 WESLEYS RUN
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-1049
Mailing Address - Country:US
Mailing Address - Phone:610-613-9177
Mailing Address - Fax:
Practice Address - Street 1:219 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TRAPPE
Practice Address - State:PA
Practice Address - Zip Code:19426-2000
Practice Address - Country:US
Practice Address - Phone:610-489-8331
Practice Address - Fax:610-489-1563
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0354331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice