Provider Demographics
NPI:1700900156
Name:LEE, KYUNG AE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:AE
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 1:6464 RAVEN HALL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-1301
Mailing Address - Country:US
Mailing Address - Phone:702-732-1293
Mailing Address - Fax:
Practice Address - Street 1:7310 SMOKE RANCH RD
Practice Address - Street 2:# F
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0258
Practice Address - Country:US
Practice Address - Phone:702-254-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV50651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice