Provider Demographics
NPI:1427207273
Name:LEE, SU KYONG
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:KYONG
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13822 SAN ANTONIO DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4033
Mailing Address - Country:US
Mailing Address - Phone:562-868-6719
Mailing Address - Fax:564-864-5694
Practice Address - Street 1:13822 SAN ANTONIO DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4033
Practice Address - Country:US
Practice Address - Phone:562-868-6719
Practice Address - Fax:564-864-5694
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist