Healthcare Provider Details

I. General information

NPI: 1073235719
Provider Name (Legal Business Name): WON J LEE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COLLEGE AVE
ALTON IL
62002-4742
US

IV. Provider business mailing address

1209 CHANCELLOR DR
EDWARDSVILLE IL
62025-3951
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-7170
  • Fax:
Mailing address:
  • Phone: 443-632-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: