Provider Demographics
NPI:1194198036
Name:LEE, JUN
Entity Type:Individual
Prefix:
First Name:JUN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 E PACHECO BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4951
Mailing Address - Country:US
Mailing Address - Phone:209-826-8600
Mailing Address - Fax:
Practice Address - Street 1:1989 E PACHECO BLVD STE I
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4951
Practice Address - Country:US
Practice Address - Phone:209-826-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist