Provider Demographics
NPI:1477567154
Name:LEE, JIYOUNG ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIYOUNG
Middle Name:ELIZABETH
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 NW COUNCIL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3724
Mailing Address - Country:US
Mailing Address - Phone:503-666-9436
Mailing Address - Fax:503-912-0757
Practice Address - Street 1:831 NW COUNCIL DR STE 210
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3724
Practice Address - Country:US
Practice Address - Phone:503-666-9436
Practice Address - Fax:503-912-0757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208081223P0221X
ORD87761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028475OtherOMAP