Provider Demographics
NPI:1124305057
Name:LEE, JONG S (DDS)
Entity type:Individual
Prefix:
First Name:JONG
Middle Name:S
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 1:4855 RIVER GREEN PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8333
Mailing Address - Country:US
Mailing Address - Phone:770-500-3757
Mailing Address - Fax:
Practice Address - Street 1:4855 RIVER GREEN PKWY STE 110
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8333
Practice Address - Country:US
Practice Address - Phone:770-500-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6842-151223G0001X
GADN0143111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice