MEDICARE: LUCID DENTAL LLC

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

General Provider Information

NPI Number	:	1477417467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCID DENTAL LLC

Provider Business Mailing Address
First Line	:	105 PROFESSIONAL CT SE
Second Line	:
City	:	CALHOUN
State	:	GA
Zip	:	30701-7036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 PROFESSIONAL CT SE
Second Line	:
City	:	CALHOUN
State	:	GA
Zip	:	30701-7036
Country	:	US
Telephone Number	:	917-745-2019
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAE WOO LEE
Credential	:	DDS
Telephone Number	:	917-745-2019

Provider Enumeration Date	:	12/12/2025
Last Update Date	:	03/17/2026

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Directions to “LUCID DENTAL LLC ” Practice Location

Language	Start Address	Practice Location

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