Provider Demographics
NPI:1740954320
Name:LEE, SANGHWAN RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:SANGHWAN
Middle Name:RYAN
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 FREE ST UNIT 405
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 TOPSHAM FAIR MALL RD
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1772
Practice Address - Country:US
Practice Address - Phone:207-729-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN49051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice