Provider Demographics
NPI:1942209770
Name:BOEN, KYUNG LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:LEE
Last Name:BOEN
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 1:1786 AVENIDA REGINA
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-4209
Mailing Address - Country:US
Mailing Address - Phone:760-212-2276
Mailing Address - Fax:
Practice Address - Street 1:1786 AVENIDA REGINA
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069
Practice Address - Country:US
Practice Address - Phone:760-212-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2019-03-17
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
CA52181122300000X, 122300000X
WADE 00007737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist