MEDICARE: DR. SEON YEONG LEE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401418160	VA
2	1223G0001X	General Practice Dentistry	17740	MD
3	1223G0001X	General Practice Dentistry	DEN2000178	DC

General Provider Information

NPI Number	:	1003550088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SEON YEONG LEE DMD

Provider Business Mailing Address
First Line	:	11433 LOG RIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-8528
Country	:	US
Telephone Number	:	205-276-1725
Fax Number	:

Provider Business Practice Location Address
First Line	:	1531 MARYLAND AVE NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-7604
Country	:	US
Telephone Number	:	202-602-1672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	10/14/2022

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