Healthcare Provider Details

I. General information

NPI: 1699289645
Provider Name (Legal Business Name): DR. JAE WON LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66450 PIERSON BLVD
DESERT HOT SPRINGS CA
92240-3672
US

IV. Provider business mailing address

11072 WILSON CV
LOMA LINDA CA
92354-6512
US

V. Phone/Fax

Practice location:
  • Phone: 760-329-2191
  • Fax: 760-329-3581
Mailing address:
  • Phone: 907-346-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number65273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: