Healthcare Provider Details

I. General information

NPI: 1437629094
Provider Name (Legal Business Name): SO YEUN LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 ZONAL AVE. OPD 5 EAST #5P77
LOS ANGELES CA
90033
US

IV. Provider business mailing address

1231 S HILL ST APT 256
LOS ANGELES CA
90015-4194
US

V. Phone/Fax

Practice location:
  • Phone: 857-205-1615
  • Fax:
Mailing address:
  • Phone: 857-205-1615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: