Provider Demographics
NPI:1790862548
Name:LEE, GRACE JI YEON PARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:JI YEON PARK
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6104
Mailing Address - Country:US
Mailing Address - Phone:928-726-7041
Mailing Address - Fax:928-726-2638
Practice Address - Street 1:1805 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6104
Practice Address - Country:US
Practice Address - Phone:928-726-7041
Practice Address - Fax:928-726-2638
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5582122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist