Healthcare Provider Details

I. General information

NPI: 1720714454
Provider Name (Legal Business Name): SUNNY JISUN LEE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 MIRAMONTE AVE STE 9
MOUNTAIN VIEW CA
94040-3718
US

IV. Provider business mailing address

150 MARKET ST. 428
MILPITAS CA
95035
US

V. Phone/Fax

Practice location:
  • Phone: 650-282-5758
  • Fax:
Mailing address:
  • Phone: 310-944-1635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number109995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: