Provider Demographics
NPI:1467642181
Name:LEE, KYU JIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYU
Middle Name:JIN
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 1:200 BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4785
Mailing Address - Country:US
Mailing Address - Phone:804-559-1016
Mailing Address - Fax:804-559-1018
Practice Address - Street 1:7126 MECHANICSVILLE TPKE
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-3628
Practice Address - Country:US
Practice Address - Phone:804-559-1016
Practice Address - Fax:804-559-1018
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice