Provider Demographics
NPI:1275757254
Name:LEE, KYUNG SOOK (DMD)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:SOOK
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:KYUNG SOOK
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1499 SE 1ST AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-6772
Mailing Address - Country:US
Mailing Address - Phone:503-263-1234
Mailing Address - Fax:503-263-4075
Practice Address - Street 1:1499 SE 1ST AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-6772
Practice Address - Country:US
Practice Address - Phone:503-263-1234
Practice Address - Fax:503-263-4075
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist