Provider Demographics
NPI:1861826935
Name:LEE, ILKYU JASON (DMD)
Entity Type:Individual
Prefix:DR
First Name:ILKYU
Middle Name:JASON
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 1:1160 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4143
Mailing Address - Country:US
Mailing Address - Phone:503-363-3311
Mailing Address - Fax:503-364-4950
Practice Address - Street 1:1160 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4143
Practice Address - Country:US
Practice Address - Phone:503-363-3311
Practice Address - Fax:503-364-4950
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6545122300000X
ORD10102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist