Provider Demographics
NPI:1205219318
Name:LEE, EOM JI (DMD)
Entity Type:Individual
Prefix:
First Name:EOM JI
Middle Name:
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 1:2760 JEFFERSON CENTRE WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8266
Mailing Address - Country:US
Mailing Address - Phone:812-284-2206
Mailing Address - Fax:812-284-2216
Practice Address - Street 1:2760 JEFFERSON CENTRE WAY STE 2
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8266
Practice Address - Country:US
Practice Address - Phone:812-284-2206
Practice Address - Fax:812-284-2216
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9637122300000X
IN12012839A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist