Provider Demographics
NPI:1174646632
Name:LEE, JAE YONG (DDS)
Entity Type:Individual
Prefix:MR
First Name:JAE YONG
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 1:505 S. VIRGIL AVE.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-382-0022
Mailing Address - Fax:213-382-0020
Practice Address - Street 1:505 S. VIRGIL AVE.
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-382-0022
Practice Address - Fax:213-382-0020
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47932122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist