Provider Demographics
NPI:1942573118
Name:JIYOUNG E LEE DMD PC
Entity Type:Organization
Organization Name:JIYOUNG E LEE DMD PC
Other - Org Name:GRESHAM PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-666-9436
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:STE 210
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-761-2243
Mailing Address - Fax:503-761-1540
Practice Address - Street 1:831 NW COUNCIL DR STE 210
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3724
Practice Address - Country:US
Practice Address - Phone:503-666-9436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD87761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028475Medicaid