Provider Demographics
NPI:1154981256
Name:LEE, MINYOUNG
Entity type:Individual
Prefix:
First Name:MINYOUNG
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 1:1788 N ZARAGOZA RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7909
Mailing Address - Country:US
Mailing Address - Phone:915-849-9000
Mailing Address - Fax:
Practice Address - Street 1:1617 PLEASONTON RD
Practice Address - Street 2:SUITE G129
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-7990
Practice Address - Country:US
Practice Address - Phone:915-895-3678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35125122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist