Healthcare Provider Details

I. General information

NPI: 1861310237
Provider Name (Legal Business Name): JINA LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 BEAVER RUIN RD NW STE A
LILBURN GA
30047-3401
US

IV. Provider business mailing address

5171 GLADE PARK DR
LILBURN GA
30047-2300
US

V. Phone/Fax

Practice location:
  • Phone: 770-925-3300
  • Fax:
Mailing address:
  • Phone: 404-984-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124204
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: