Provider Demographics
NPI:1255708830
Name:LEE, SOO JI (DMD)
Entity type:Individual
Prefix:DR
First Name:SOO JI
Middle Name:
Last Name:LEE
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 1:320 BOSTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5213
Mailing Address - Country:US
Mailing Address - Phone:203-375-1388
Mailing Address - Fax:
Practice Address - Street 1:258 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2641
Practice Address - Country:US
Practice Address - Phone:860-437-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0112901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice