Provider Demographics
NPI:1750501540
Name:LEE, DAE WON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAE
Middle Name:WON
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 1:75 SUNFLOWER ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4211
Mailing Address - Country:US
Mailing Address - Phone:909-312-1076
Mailing Address - Fax:
Practice Address - Street 1:12190 PERRIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7422
Practice Address - Country:US
Practice Address - Phone:951-486-0550
Practice Address - Fax:951-486-0566
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice