Provider Demographics
NPI:1376950063
Name:LEE, SOOLIM
Entity Type:Individual
Prefix:DR
First Name:SOOLIM
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 WASHINGTON BLVD
Mailing Address - Street 2:606S
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2451
Mailing Address - Country:US
Mailing Address - Phone:516-987-8921
Mailing Address - Fax:
Practice Address - Street 1:666 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3775
Practice Address - Country:US
Practice Address - Phone:203-889-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist