Provider Demographics
NPI:1982871778
Name:LEE, JIN (DDS)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:
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 1:7917 MCPHERSON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-2811
Mailing Address - Country:US
Mailing Address - Phone:956-712-8444
Mailing Address - Fax:956-712-8439
Practice Address - Street 1:7917 MCPHERSON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-2811
Practice Address - Country:US
Practice Address - Phone:956-712-8444
Practice Address - Fax:956-712-8439
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161773002Medicaid
TXG6003101OtherCHIP