Provider Demographics
NPI:1740586577
Name:LEE, YOUNG AE
Entity Type:Individual
Prefix:
First Name:YOUNG AE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S RADISSON APT 1
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-4391
Mailing Address - Country:US
Mailing Address - Phone:646-593-1159
Mailing Address - Fax:
Practice Address - Street 1:3601 BUDDY OWENS AVE
Practice Address - Street 2:SUIT 200
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-6446
Practice Address - Country:US
Practice Address - Phone:646-593-1159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104401223G0001X
TX273851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice