Provider Demographics
NPI:1932986056
Name:LEE, KYU JIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYU JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 CEMO CIR APT 4327
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-8169
Mailing Address - Country:US
Mailing Address - Phone:310-405-9363
Mailing Address - Fax:
Practice Address - Street 1:2550 DOUGLAS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3996
Practice Address - Country:US
Practice Address - Phone:916-786-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1093591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics