Provider Demographics
NPI:1255688214
Name:LEE, SOONKI (DMD)
Entity Type:Individual
Prefix:
First Name:SOONKI
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 W OLYMPIC BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6507
Mailing Address - Country:US
Mailing Address - Phone:213-384-1036
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 216
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6507
Practice Address - Country:US
Practice Address - Phone:213-384-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA621641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty