Provider Demographics
NPI:1063113439
Name:LEE, PHILIP JUNHO
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JUNHO
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6389
Mailing Address - Country:US
Mailing Address - Phone:573-290-3111
Mailing Address - Fax:
Practice Address - Street 1:3070 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6389
Practice Address - Country:US
Practice Address - Phone:573-290-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240301901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice