MEDICARE: JAE WON LEE DDS, INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1265148605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAE WON LEE DDS, INC

Provider Business Mailing Address
First Line	:	11072 WILSON CV
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-6512
Country	:	US
Telephone Number	:	907-346-0130
Fax Number	:

Provider Business Practice Location Address
First Line	:	66450 PIERSON BLVD
Second Line	:
City	:	DESERT HOT SPRINGS
State	:	CA
Zip	:	92240-3672
Country	:	US
Telephone Number	:	907-346-0130
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	JAE WON LEE
Credential	:	DDS
Telephone Number	:	907-346-0130

Provider Enumeration Date	:	01/30/2023
Last Update Date	:	04/02/2023

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