Provider Demographics
NPI:1780221101
Name:LEE, JONG MOON (DDS)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:MOON
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 1:1108 SO. DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765
Mailing Address - Country:US
Mailing Address - Phone:909-861-4444
Mailing Address - Fax:909-861-9654
Practice Address - Street 1:1108 SO. DIAMOND BAR BLVD. DIAMOND BAR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765
Practice Address - Country:US
Practice Address - Phone:909-861-4444
Practice Address - Fax:909-861-9654
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice