=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679958458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOO YUN S LEE DMD LLA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2015
-----------------------------------------------------
Last Update Date | 07/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8761 PINEY ORCHARD PKWY A
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-7207
-----------------------------------------------------
Fax | 410-672-7205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8761 PINEY ORCHARD PKWY A
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-7207
-----------------------------------------------------
Fax | 410-672-7205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | SOO YUN LEE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 410-672-7207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 13674
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------