Provider Demographics
NPI:1508384298
Name:LEE, JUNG SUP (DMD)
Entity Type:Individual
Prefix:
First Name:JUNG SUP
Middle Name:
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 1:2480 PASCOLI PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4537
Mailing Address - Country:US
Mailing Address - Phone:859-420-8706
Mailing Address - Fax:
Practice Address - Street 1:2250 LEESTOWN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1052
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-02
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100261223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist