Provider Demographics
NPI:1770830622
Name:LEE, JAESEOP (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAESEOP
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 1:25 LORING ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-4714
Mailing Address - Country:US
Mailing Address - Phone:617-308-2805
Mailing Address - Fax:
Practice Address - Street 1:211 LOWELL ST UNIT K
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-3014
Practice Address - Country:US
Practice Address - Phone:978-657-4550
Practice Address - Fax:978-657-5828
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH039271223G0001X
MADN18567151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice