Healthcare Provider Details

I. General information

NPI: 1598050957
Provider Name (Legal Business Name): EUNSUK LEE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HUDSON ST
SOUTH GLENS FALLS NY
12803
US

IV. Provider business mailing address

4 BEVSWOOD OAKS
CLIFTON PARK NY
12065-8746
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-2187
  • Fax:
Mailing address:
  • Phone: 518-357-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056145
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: