Provider Demographics
NPI:1629189980
Name:LEE, MOON SOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOON
Middle Name:SOO
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 1:2397 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3229
Mailing Address - Country:US
Mailing Address - Phone:203-372-8961
Mailing Address - Fax:203-372-1948
Practice Address - Street 1:2397 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3229
Practice Address - Country:US
Practice Address - Phone:203-372-8961
Practice Address - Fax:203-372-1948
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice