Provider Demographics
NPI:1700203114
Name:KWANSOO LEE, DDS, PLLC
Entity Type:Organization
Organization Name:KWANSOO LEE, DDS, PLLC
Other - Org Name:SPANAWAY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KWANSOO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-777-0550
Mailing Address - Street 1:20709 MOUNTAIN HIGHWAY E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8580
Mailing Address - Country:US
Mailing Address - Phone:253-777-0550
Mailing Address - Fax:253-617-0208
Practice Address - Street 1:20709 MOUNTAIN HIGHWAY E
Practice Address - Street 2:SUITE 101
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8580
Practice Address - Country:US
Practice Address - Phone:253-777-0550
Practice Address - Fax:253-617-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602939041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty