Provider Demographics
NPI:1659598407
Name:LEE, JUNGWOO (DMD)
Entity Type:Individual
Prefix:
First Name:JUNGWOO
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 FELLSWAY
Mailing Address - Street 2:2ND FL
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4959
Mailing Address - Country:US
Mailing Address - Phone:781-306-9644
Mailing Address - Fax:781-306-9726
Practice Address - Street 1:616 FELLSWAY
Practice Address - Street 2:2ND FL
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4959
Practice Address - Country:US
Practice Address - Phone:781-306-9644
Practice Address - Fax:781-306-9726
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20719122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist