Healthcare Provider Details

I. General information

NPI: 1891495511
Provider Name (Legal Business Name): JAEWOO LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MAIN ST # 86
TAUNTON MA
02780-2736
US

IV. Provider business mailing address

231 HARRISON AVE APT 23
BOSTON MA
02111-1858
US

V. Phone/Fax

Practice location:
  • Phone: 508-821-9041
  • Fax:
Mailing address:
  • Phone: 617-909-8945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10000408
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: