Healthcare Provider Details

I. General information

NPI: 1730400797
Provider Name (Legal Business Name): DAVID SUNGKU LEE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12506 LAKE RIDGE DR
WOODBRIDGE VA
22192-2397
US

IV. Provider business mailing address

5509 QUAIL CT
CLIFTON VA
20124-0903
US

V. Phone/Fax

Practice location:
  • Phone: 571-572-3445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401416024
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: