Healthcare Provider Details

I. General information

NPI: 1548545676
Provider Name (Legal Business Name): EUGENIE EUNKYUNG LEE D.M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 CENTRE ST
NUTLEY NJ
07110-2877
US

IV. Provider business mailing address

230 CENTRE ST
NUTLEY NJ
07110-2877
US

V. Phone/Fax

Practice location:
  • Phone: 973-661-2992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI02404500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: