Provider Demographics
NPI:1588311856
Name:LEE, JIYEON
Entity type:Individual
Prefix:
First Name:JIYEON
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 1:370 GRAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4109
Mailing Address - Country:US
Mailing Address - Phone:201-871-3555
Mailing Address - Fax:
Practice Address - Street 1:16108 ASH WAY STE 202
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-8781
Practice Address - Country:US
Practice Address - Phone:201-871-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA613131361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1588311856OtherNPI