Provider Demographics
NPI:1689725004
Name:LEE, SU YIM (DDS)
Entity Type:Individual
Prefix:
First Name:SU YIM
Middle Name:
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 1:4801 FREEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-2101
Mailing Address - Country:US
Mailing Address - Phone:916-456-1013
Mailing Address - Fax:916-456-1932
Practice Address - Street 1:4801 FREEPORT BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-2101
Practice Address - Country:US
Practice Address - Phone:916-456-1013
Practice Address - Fax:916-456-1932
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA542771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice