Provider Demographics
NPI:1598258808
Name:LEE, JEONG MIN (DDS)
Entity Type:Individual
Prefix:
First Name:JEONG MIN
Middle Name:
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 1:636 BROOKLYN AVE APT 5J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1616
Mailing Address - Country:US
Mailing Address - Phone:917-355-4268
Mailing Address - Fax:
Practice Address - Street 1:3200 ANDREWS HWY STE 400
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3950
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice