Provider Demographics
NPI:1700516705
Name:LEEM, MIKE MOOYUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:MOOYUL
Last Name:LEEM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 LIPIZZAN DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-0547
Mailing Address - Country:US
Mailing Address - Phone:469-212-3017
Mailing Address - Fax:
Practice Address - Street 1:6000 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5606
Practice Address - Country:US
Practice Address - Phone:817-585-2492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX385321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice