Provider Demographics
NPI:1497188247
Name:LEE, ROBERT CHULSUNG (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHULSUNG
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 1:4305 76TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3749
Mailing Address - Country:US
Mailing Address - Phone:360-653-4114
Mailing Address - Fax:360-658-9597
Practice Address - Street 1:4305 76TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270
Practice Address - Country:US
Practice Address - Phone:360-653-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA628021223G0001X
WADE606602011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice