MEDICARE: JL DENTAL ASSOCIATES, 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	261QD0000X	Dental Clinic/Center	22160	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110079450A	OTHER	MA	MASS HEALTH PROVIDER

General Provider Information

NPI Number	:	1558642827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JL DENTAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1892 CENTRE ST
Second Line	:
City	:	WEST ROXBURY
State	:	MA
Zip	:	02132-1924
Country	:	US
Telephone Number	:	617-327-1350
Fax Number	:	617-327-1573

Provider Business Practice Location Address
First Line	:	1892 CENTRE ST
Second Line	:
City	:	WEST ROXBURY
State	:	MA
Zip	:	02132-1924
Country	:	US
Telephone Number	:	617-327-1350
Fax Number	:	617-327-1573

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. JONATHAN JUNGHO LEE
Credential	:	DMD
Telephone Number	:	617-327-1350

Provider Enumeration Date	:	08/31/2011
Last Update Date	:	08/31/2011

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Directions to “JL DENTAL ASSOCIATES, LLC ” Practice Location

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