Provider Demographics
NPI:1285263012
Name:LEE, JAE YONG (DMD PHD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:YONG
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 BARNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 BARNWOOD DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2585
Practice Address - Country:US
Practice Address - Phone:859-474-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11405122300000X
KY10520122300000X
IN12013758A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist