Provider Demographics
NPI:1396278503
Name:LEE, SEONG WOO (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:SEONG WOO
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 VIKING DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3522
Mailing Address - Country:US
Mailing Address - Phone:507-208-9124
Mailing Address - Fax:
Practice Address - Street 1:2112 VIKING DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3522
Practice Address - Country:US
Practice Address - Phone:507-208-9124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND138451223S0112X, 1223P0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program