Provider Demographics
NPI:1508539503
Name:LEE, DANIEL DEOKCHUN
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:DEOKCHUN
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 HACKENSACK AVE APT 1315
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6579
Mailing Address - Country:US
Mailing Address - Phone:929-367-1257
Mailing Address - Fax:
Practice Address - Street 1:1455 BROAD ST STE 105
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3039
Practice Address - Country:US
Practice Address - Phone:862-702-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02852700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist