Provider Demographics
NPI:1063920858
Name:LEE, JASON JUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:JUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VISTA MONTANA APT 1202
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2718
Mailing Address - Country:US
Mailing Address - Phone:408-309-5501
Mailing Address - Fax:
Practice Address - Street 1:2486 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1421
Practice Address - Country:US
Practice Address - Phone:408-309-5501
Practice Address - Fax:408-309-5501
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA628581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty