Provider Demographics
NPI:1154763498
Name:LEE, SOO YUN
Entity type:Individual
Prefix:
First Name:SOO YUN
Middle Name:
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 1:15801 ARTIST WAY
Mailing Address - Street 2:APT # 4208
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6177
Mailing Address - Country:US
Mailing Address - Phone:917-363-8223
Mailing Address - Fax:
Practice Address - Street 1:15801 ARTIST WAY
Practice Address - Street 2:APT # 4208
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-6177
Practice Address - Country:US
Practice Address - Phone:917-363-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist