Provider Demographics
NPI:1124042049
Name:LEE, SUSAN HAE KYUNG (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:HAE KYUNG
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 1:3280 HOWELL MILL RD NW STE 121
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4107
Mailing Address - Country:US
Mailing Address - Phone:404-355-8557
Mailing Address - Fax:404-355-8321
Practice Address - Street 1:3280 HOWELL MILL RD NW STE 121
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4107
Practice Address - Country:US
Practice Address - Phone:404-355-8557
Practice Address - Fax:404-355-8321
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000821895DMedicaid