MEDICARE: HAEEUN LEE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN30661	FL

General Provider Information

NPI Number	:	1114816246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAEEUN LEE DMD

Provider Business Mailing Address
First Line	:	600 TECHNOLOGY PARK STE 101
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-7122
Country	:	US
Telephone Number	:	407-543-8514
Fax Number	:

Provider Business Practice Location Address
First Line	:	5116 BLANDING BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-7840
Country	:	US
Telephone Number	:	904-573-7900
Fax Number	:	904-903-4537

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2025
Last Update Date	:	07/02/2025

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