Provider Demographics
NPI:1760833958
Name:JUNGWOO LEE
Entity Type:Organization
Organization Name:JUNGWOO LEE
Other - Org Name:DENTAL EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUNGWOO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-233-2003
Mailing Address - Street 1:7545 W BELL RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3832
Mailing Address - Country:US
Mailing Address - Phone:480-233-2003
Mailing Address - Fax:
Practice Address - Street 1:7545 W BELL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3832
Practice Address - Country:US
Practice Address - Phone:480-233-2003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008679305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ134238Medicaid