Provider Demographics
NPI:1033184882
Name:LEE, BYUNG JAE JACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:BYUNG JAE
Middle Name:JACK
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10551 ALLEN RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-3305
Mailing Address - Country:US
Mailing Address - Phone:313-388-1100
Mailing Address - Fax:313-388-5633
Practice Address - Street 1:10551 ALLEN RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-3305
Practice Address - Country:US
Practice Address - Phone:313-388-1100
Practice Address - Fax:313-388-5633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist