Healthcare Provider Details

I. General information

NPI: 1063816239
Provider Name (Legal Business Name): JAE RHEE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10510 GRAVELLY LAKE DR SW STE 100
LAKEWOOD WA
98499-5037
US

IV. Provider business mailing address

1019 PACIFIC AVE STE. 300
TACOMA WA
98402-4443
US

V. Phone/Fax

Practice location:
  • Phone: 253-589-7030
  • Fax: 253-284-4384
Mailing address:
  • Phone: 253-597-4550
  • Fax: 253-597-4556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60485185
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: