Provider Demographics
NPI:1336125442
Name:LEE, KWANG MYUNG SIMON (DMD)
Entity type:Individual
Prefix:DR
First Name:KWANG MYUNG
Middle Name:SIMON
Last Name:LEE
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 KAKALA ST UNIT 1401
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4632
Mailing Address - Country:US
Mailing Address - Phone:808-353-8433
Mailing Address - Fax:808-638-3374
Practice Address - Street 1:724 KAKALA ST UNIT 1401
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-4632
Practice Address - Country:US
Practice Address - Phone:808-353-8433
Practice Address - Fax:808-638-3374
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030250L1223G0001X
HIDT-22751223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice