Provider Demographics
NPI:1609217736
Name:LEE, JAE BUM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:BUM
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 1:401 S GLENOAKS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2707
Mailing Address - Country:US
Mailing Address - Phone:818-566-4438
Mailing Address - Fax:
Practice Address - Street 1:401 S GLENOAKS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2707
Practice Address - Country:US
Practice Address - Phone:818-566-4438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist