Provider Demographics
NPI:1912429101
Name:LEE, WON JONG (DDS MD)
Entity Type:Individual
Prefix:
First Name:WON JONG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 N ATLANTIC BLVD APT 209
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-2223
Mailing Address - Country:US
Mailing Address - Phone:310-715-9585
Mailing Address - Fax:
Practice Address - Street 1:2835 SAINT ROSE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4847
Practice Address - Country:US
Practice Address - Phone:310-715-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101135122300000X, 1223S0112X
NVS2-203C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist