Provider Demographics
NPI:1376820365
Name:LEE, JIN KUK (DDS)
Entity Type:Individual
Prefix:
First Name:JIN KUK
Middle Name:
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 1:5945 W PARKER RD APT 1114
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7759
Mailing Address - Country:US
Mailing Address - Phone:310-968-6125
Mailing Address - Fax:
Practice Address - Street 1:2440 N JOSEY LN STE 103
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1697
Practice Address - Country:US
Practice Address - Phone:310-968-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX275131223G0001X
WADE60242044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist