Provider Demographics
NPI:1205117421
Name:LEE, SEUNG JAE (DMD)
Entity type:Individual
Prefix:DR
First Name:SEUNG JAE
Middle Name:
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 1:1401 PARK AVE
Mailing Address - Street 2:#503
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3595
Mailing Address - Country:US
Mailing Address - Phone:415-314-3210
Mailing Address - Fax:
Practice Address - Street 1:2288 DANIELS ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6706
Practice Address - Country:US
Practice Address - Phone:209-456-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist