Healthcare Provider Details

I. General information

NPI: 1508261264
Provider Name (Legal Business Name): JOHN KEUNHEE LEE D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DR. JOHN MARK AN

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5024
APO AP
96319-5024
US

IV. Provider business mailing address

UNIT 5024
APO AP
96319-5024
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-6700
  • Fax:
Mailing address:
  • Phone: 315-226-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019030490
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN00203948
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12012235A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: