=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225137045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN H LEE DMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 02/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3280 HOWELL MILL RD NW STE 121
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30327-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-355-8557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3280 HOWELL MILL RD NW STE 121
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30327-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-355-8557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. SUSAN HAE-KYUNG LEE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 404-355-8557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN011872
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------