Provider Demographics
NPI:1831210558
Name:LEE, KOOK SUNG (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:KOOK
Middle Name:SUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:CALVIN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, MS
Mailing Address - Street 1:818 N EASTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-3808
Mailing Address - Country:US
Mailing Address - Phone:215-885-6020
Mailing Address - Fax:215-885-0665
Practice Address - Street 1:818 N EASTON RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-3808
Practice Address - Country:US
Practice Address - Phone:215-885-6020
Practice Address - Fax:215-885-0665
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029803L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics