Provider Demographics
NPI:1356402556
Name:LEE, JINAH (DDS)
Entity type:Individual
Prefix:DR
First Name:JINAH
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4731 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-4150
Mailing Address - Country:US
Mailing Address - Phone:602-470-9191
Mailing Address - Fax:602-470-9731
Practice Address - Street 1:4731 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4150
Practice Address - Country:US
Practice Address - Phone:602-470-9191
Practice Address - Fax:602-470-9731
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1587028OtherUNITED CONCORDIA
AZF14635OtherPHOENIX HEALTH PLAN
AZ5870OtherSTATE DENTAL LICENSE
0413620OtherBLUECROSS BLUESHIELD
AZ854829OtherAHCCCS