Provider Demographics
NPI:1518451103
Name:LEE, SOO JIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SOO JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26440 LA ALAMEDA STE 320
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6304
Mailing Address - Country:US
Mailing Address - Phone:949-445-1234
Mailing Address - Fax:949-445-1337
Practice Address - Street 1:26440 LA ALAMEDA STE 320
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6304
Practice Address - Country:US
Practice Address - Phone:949-445-1234
Practice Address - Fax:949-445-1337
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1083951223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial PainGroup - Single Specialty