Provider Demographics
NPI:1487631339
Name:LEE, SOOMO (DDS)
Entity Type:Individual
Prefix:
First Name:SOOMO
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:DENTAC
Mailing Address - Street 2:618 MD CO DENTAL
Mailing Address - City:YONGHSAN
Mailing Address - State:REPUBLIC OF KOREA
Mailing Address - Zip Code:APO AP 96205
Mailing Address - Country:KR
Mailing Address - Phone:8227-916-8803
Mailing Address - Fax:
Practice Address - Street 1:DENTAC
Practice Address - Street 2:618 MD CO DENTAL
Practice Address - City:YONGHSAN
Practice Address - State:REPUBLIC OF KOREA
Practice Address - Zip Code:APO AP 96205
Practice Address - Country:KR
Practice Address - Phone:8227-916-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190262551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice