Provider Demographics
NPI:1063554061
Name:LEE, JIN BOONE
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:BOONE
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4959 ARLINGTON AVE STE F
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2756
Mailing Address - Country:US
Mailing Address - Phone:951-353-8454
Mailing Address - Fax:951-352-4006
Practice Address - Street 1:4959 ARLINGTON AVE STE F
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2756
Practice Address - Country:US
Practice Address - Phone:951-353-8454
Practice Address - Fax:951-352-4006
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA333211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice