Provider Demographics
NPI:1942761648
Name:LEE, CLARA TAEYOON
Entity Type:Individual
Prefix:DR
First Name:CLARA
Middle Name:TAEYOON
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 CRESCENT ST APT 1810
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4260
Mailing Address - Country:US
Mailing Address - Phone:347-921-1098
Mailing Address - Fax:
Practice Address - Street 1:82-68 164TH ST
Practice Address - Street 2:N BUILDING ROOM 633
Practice Address - City:QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-883-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA