Provider Demographics
NPI:1821612904
Name:LEE, SO JUNG (DMD)
Entity Type:Individual
Prefix:
First Name:SO JUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 FAIRFAX BLVD APT 1504
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2422
Mailing Address - Country:US
Mailing Address - Phone:703-969-4878
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 109
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2460
Practice Address - Country:US
Practice Address - Phone:703-830-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0261641223G0001X
VA04014172231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice