Provider Demographics
NPI:1922786664
Name:LEE, JOOSANG
Entity Type:Individual
Prefix:
First Name:JOOSANG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 US HIGHWAY 259 N APT 1004
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7781
Mailing Address - Country:US
Mailing Address - Phone:412-708-5791
Mailing Address - Fax:
Practice Address - Street 1:879 US HIGHWAY 271 N # 100
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-5580
Practice Address - Country:US
Practice Address - Phone:903-680-2051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist