Healthcare Provider Details

I. General information

NPI: 1750498358
Provider Name (Legal Business Name): WON KOO LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CALIFORNIA AVE SUITE A
SAND CITY CA
93955-3150
US

IV. Provider business mailing address

2030 CALIFORNIA AVE SUITE A
SAND CITY CA
93955-3150
US

V. Phone/Fax

Practice location:
  • Phone: 831-393-1600
  • Fax: 831-393-2600
Mailing address:
  • Phone: 831-393-1600
  • Fax: 831-393-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number34367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: