=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144977687
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAESUN LEE DENTIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2022
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3838 BRIDGEPORT WAY W
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-4416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-212-3430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1959 NE PACIFIC STREET BOX 357134 UW DEPARTMENT OF ORAL SURGERY
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 61426269
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DR61286418
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN30054
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------