Provider Demographics
NPI:1124172879
Name:LEE, JONG S
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:S
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 1:14416 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 16
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-2801
Mailing Address - Country:US
Mailing Address - Phone:703-492-1999
Mailing Address - Fax:703-492-6379
Practice Address - Street 1:14416 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 16
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-2801
Practice Address - Country:US
Practice Address - Phone:703-492-1999
Practice Address - Fax:703-492-6379
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice