Provider Demographics
NPI:1760694020
Name:LEE, MOONSAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOONSAE
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 1:127 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1441
Mailing Address - Country:US
Mailing Address - Phone:201-944-7236
Mailing Address - Fax:
Practice Address - Street 1:127 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1441
Practice Address - Country:US
Practice Address - Phone:201-944-7236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ149831223G0001X
NY377361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice