Provider Demographics
NPI:1386930394
Name:LEE, JA EUN (DDS)
Entity type:Individual
Prefix:DR
First Name:JA EUN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAJA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1777 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4909
Mailing Address - Country:US
Mailing Address - Phone:931-202-9151
Mailing Address - Fax:
Practice Address - Street 1:1777 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4909
Practice Address - Country:US
Practice Address - Phone:931-202-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6737-015122300000X
GADN014745122300000X
TN00000117511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist