Healthcare Provider Details

I. General information

NPI: 1659566750
Provider Name (Legal Business Name): DONG S LEE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US ARMY DENTAL HEALTH ACTIVITY 520 POPE AVENUE
FORT LEAVENWORTH KS
66027
US

IV. Provider business mailing address

US ARMY DENTAL HEALTH ACTIVITY 520 POPE AVENUE
FORT LEAVENWORTH KS
66027
US

V. Phone/Fax

Practice location:
  • Phone: 913-684-5516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5548
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5548
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: