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General NPI Number Information
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NPI Number | 1548990005
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Entity Type | Individual
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Provider Name | JAE WOO LEE
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Gender | Male
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Dates
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Enumeration Date | 06/15/2022
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Last Update Date | 12/12/2025
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Provider Practice Location Address
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Address Line | 105 PROFESSIONAL CT SE
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City | CALHOUN
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State | GA
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Zip | 30701-7036
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Country | US
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Telephone | 917-745-2019
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Fax |
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Provider Business Mailing Address
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Address Line | 1650 N ROBERTS RD NW APT 2202
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City | KENNESAW
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State | GA
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Zip | 30144-3778
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Country | US
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Telephone | 917-745-2019
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN123111
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License Number State | GA
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