MEDICARE: JU YONG LEE DDS

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	1223P0221X	Pediatric Dentistry	7748	LA
2	1223G0001X	General Practice Dentistry	104283	CA
3	1223P0221X	Pediatric Dentistry	S6-238C	NV

General Provider Information

NPI Number	:	1245886894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JU YONG LEE DDS

Provider Business Mailing Address
First Line	:	4335 S GRAND CANYON DR UNIT 442
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7194
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4325 AIRLINE DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2003
Country	:	US
Telephone Number	:	318-742-9333
Fax Number	:	318-747-9089

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

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	01/09/2026

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