Provider Demographics
NPI:1245603836
Name:JEONGLEE DMDPC INC
Entity Type:Organization
Organization Name:JEONGLEE DMDPC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEONG SOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-322-4914
Mailing Address - Street 1:452 PLEASANT ST
Mailing Address - Street 2:#110
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-8117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:452 PLEASANT ST
Practice Address - Street 2:#110
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8117
Practice Address - Country:US
Practice Address - Phone:781-322-4914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty