Healthcare Provider Details

I. General information

NPI: 1548949936
Provider Name (Legal Business Name): HAJUNG LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date: 05/17/2024
Reactivation Date: 09/10/2024

III. Provider practice location address

13034 OLD COLUMBIA PIKE
SILVER SPRING MD
20904-5226
US

IV. Provider business mailing address

345 E 24 STREET
NEW YORK NY
10010
US

V. Phone/Fax

Practice location:
  • Phone: 301-384-8788
  • Fax:
Mailing address:
  • Phone: 212-998-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18262
License Number StateMD
# 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: