MEDICARE: WON JONG LEE DDS MD

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	101135	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	101135	CA
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S2-203C	NV

General Provider Information

NPI Number	:	1912429101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WON JONG LEE DDS MD

Provider Business Mailing Address
First Line	:	334 N ATLANTIC BLVD APT 209
Second Line	:
City	:	ALHAMBRA
State	:	CA
Zip	:	91801-2223
Country	:	US
Telephone Number	:	310-715-9585
Fax Number	:

Provider Business Practice Location Address
First Line	:	2835 SAINT ROSE PKWY STE 100
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-4847
Country	:	US
Telephone Number	:	310-715-9585
Fax Number	:

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

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	05/31/2023

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