Provider Demographics
NPI:1225680531
Name:LEE, SUN JOO
Entity Type:Individual
Prefix:
First Name:SUN
Middle Name:JOO
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 E ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1307
Mailing Address - Country:US
Mailing Address - Phone:804-426-9264
Mailing Address - Fax:
Practice Address - Street 1:106 FORT DALE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-2233
Practice Address - Country:US
Practice Address - Phone:334-382-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL68351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice