Provider Demographics
NPI:1235669920
Name:LEE, JI YOON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JI
Middle Name:YOON
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 1:3400 TEXAS SAGE TRL STE 136
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8604
Mailing Address - Country:US
Mailing Address - Phone:817-750-1300
Mailing Address - Fax:
Practice Address - Street 1:3400 TEXAS SAGE TRL STE 136
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8604
Practice Address - Country:US
Practice Address - Phone:817-750-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty