Provider Demographics
NPI:1720599293
Name:LEE, KANGHYUN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KANGHYUN
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 1:4482 RUGGLES CT
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5715
Mailing Address - Country:US
Mailing Address - Phone:703-340-4496
Mailing Address - Fax:
Practice Address - Street 1:406 N FRUITLAND BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-7261
Practice Address - Country:US
Practice Address - Phone:410-845-2956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD166031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice