Provider Demographics
NPI:1790178184
Name:LEE, CHUL WON (DMD)
Entity Type:Individual
Prefix:
First Name:CHUL WON
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 1:1 LONG WHARF DR STE 403
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-688-3000
Mailing Address - Fax:
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:RM 404
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-688-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY058858-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program