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General NPI Number Information
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NPI Number | 1386146314
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Entity Type | Organization
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Legal Business Name | 209 BROOKLINE DENTAL
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Dates
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Enumeration Date | 03/06/2018
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Last Update Date | 03/06/2018
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Provider Practice Location Address
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Address Line | 209 HARVARD ST STE 300
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City | BROOKLINE
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State | MA
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Zip | 02446-5005
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Country | US
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Telephone | 443-538-4129
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Fax |
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Provider Business Mailing Address
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Address Line | 210 WINTHROP RD APT 12A
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City | BROOKLINE
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State | MA
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Zip | 02445-4407
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Country | US
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Telephone | 443-538-4129
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | JOSHUA PYUNGHOON LEE
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Credential | DDS
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Telephone | 443-538-4129
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN1856823
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License Number State | MA
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