Healthcare Provider Details

I. General information

NPI: 1144481094
Provider Name (Legal Business Name): JONATHAN JUNGHO LEE D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DR. JUNG HO LEE

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1892 CENTRE ST
WEST ROXBURY MA
02132-1924
US

IV. Provider business mailing address

1892 CENTRE ST
WEST ROXBURY MA
02132-1924
US

V. Phone/Fax

Practice location:
  • Phone: 617-327-1350
  • Fax: 617-477-3394
Mailing address:
  • Phone: 617-327-1350
  • Fax: 617-477-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22160
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: