Provider Demographics
NPI:1164497319
Name:LEE, JAI GOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAI
Middle Name:GOO
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 1:2074 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-880-2025
Mailing Address - Fax:541-880-2092
Practice Address - Street 1:2074 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-880-2090
Practice Address - Fax:541-880-2092
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD86601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBL9515466OtherDEA