=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902531833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DASUM LEE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2022
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 S RANCHO DR STE 205
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-254-5038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 685 1ST AVE APT 32C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-254-5038
-----------------------------------------------------
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 | 7712
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------