=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689343105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEOKHOON LEE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2021
-----------------------------------------------------
Last Update Date | 12/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 E MARKET ST
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-899-4713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9345 CHESTNUT KNOLLS DR
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22032-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-303-7136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DT-2931
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401418168
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------