Provider Demographics
NPI:1619008034
Name:LEE, KELLY KYUNG A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KYUNG A
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 1:1066 AGATE CT
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-2485
Mailing Address - Country:US
Mailing Address - Phone:562-439-6562
Mailing Address - Fax:562-434-7892
Practice Address - Street 1:2211 E. 7TH ST.
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804
Practice Address - Country:US
Practice Address - Phone:562-439-6562
Practice Address - Fax:562-434-7892
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice