Provider Demographics
NPI:1720714454
Name:LEE, SUNNY JISUN (DDS)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:JISUN
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 1:555 MAIN AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2235
Mailing Address - Country:US
Mailing Address - Phone:310-944-1635
Mailing Address - Fax:
Practice Address - Street 1:2821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:ALLOUEZ
Practice Address - State:WI
Practice Address - Zip Code:54301-2878
Practice Address - Country:US
Practice Address - Phone:920-336-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6000043-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics