MEDICARE: DR. DONGJIN 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	122300000X	Dentist	054569	NY

General Provider Information

NPI Number	:	1043544919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONGJIN LEE DMD

Provider Business Mailing Address
First Line	:	330 W 58TH ST STE 309
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-1821
Country	:	US
Telephone Number	:	212-600-5221
Fax Number	:	917-210-3909

Provider Business Practice Location Address
First Line	:	330 W 58TH ST STE 309
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-1821
Country	:	US
Telephone Number	:	212-600-5221
Fax Number	:	917-210-3909

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

Provider Enumeration Date	:	09/25/2009
Last Update Date	:	02/26/2013

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