MEDICARE: HAEYEON 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	1223G0001X	General Practice Dentistry	D15094	MN

General Provider Information

NPI Number	:	1922840016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAEYEON LEE DDS

Provider Business Mailing Address
First Line	:	6455 THOMPSON PARK CURV S
Second Line	:
City	:	COTTAGE GROVE
State	:	MN
Zip	:	55016-4485
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 39TH AVE NE STE 225
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55421-5052
Country	:	US
Telephone Number	:	763-781-7475
Fax Number	:

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

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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Directions to “ HAEYEON LEE DDS” Practice Location

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