Provider Demographics
NPI:1508544602
Name:LEE, JAERIM (DDS)
Entity Type:Individual
Prefix:
First Name:JAERIM
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HAZARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:845-372-3692
Mailing Address - Fax:
Practice Address - Street 1:25 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:845-372-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT13890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program