Provider Demographics
NPI:1700039872
Name:LEE, JONGIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONGIN
Middle Name:
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 1:9636 GARDEN GROVE BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1590
Mailing Address - Country:US
Mailing Address - Phone:714-590-2828
Mailing Address - Fax:714-590-2848
Practice Address - Street 1:9636 GARDEN GROVE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1590
Practice Address - Country:US
Practice Address - Phone:714-590-2828
Practice Address - Fax:714-590-2848
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA541721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice