=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972050847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YOONJUNG LEE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2016
-----------------------------------------------------
Last Update Date | 04/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 S VIRGIL AVE #102
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-601-1379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 S VIRGIL AVE #102
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-601-1379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 100554
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------