Provider Demographics
NPI:1588983019
Name:LEE, KIWON (DDS)
Entity type:Individual
Prefix:DR
First Name:KIWON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BROADWAY STE 901
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-2535
Mailing Address - Country:US
Mailing Address - Phone:212-683-0174
Mailing Address - Fax:
Practice Address - Street 1:305 W GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1829
Practice Address - Country:US
Practice Address - Phone:201-746-9474
Practice Address - Fax:201-746-9473
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058305-11223G0001X
NJ22DI025915001223G0001X
VA04014131371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice