Provider Demographics
NPI:1528429321
Name:JIM LEE, LLC
Entity type:Organization
Organization Name:JIM LEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:MING-AN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-423-8867
Mailing Address - Street 1:690 PRINCE FREDERICK BLVD
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3146
Mailing Address - Country:US
Mailing Address - Phone:202-423-8867
Mailing Address - Fax:
Practice Address - Street 1:690 PRINCE FREDERICK BLVD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3146
Practice Address - Country:US
Practice Address - Phone:202-423-8867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD152591223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty