Healthcare Provider Details

I. General information

NPI: 1245886894
Provider Name (Legal Business Name): JU YONG LEE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 AIRLINE DR
BOSSIER CITY LA
71111-2003
US

IV. Provider business mailing address

4335 S GRAND CANYON DR UNIT 442
LAS VEGAS NV
89147-7194
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-9333
  • Fax: 318-747-9089
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104283
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7748
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-238C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: