Provider Demographics
NPI:1699844373
Name:LEE, MYOUNG C
Entity type:Individual
Prefix:
First Name:MYOUNG
Middle Name:C
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 1:90 WOODACRE DR
Mailing Address - Street 2:#108
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132
Mailing Address - Country:US
Mailing Address - Phone:415-329-0396
Mailing Address - Fax:415-239-4140
Practice Address - Street 1:90 WOODACRE DR
Practice Address - Street 2:#108
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132
Practice Address - Country:US
Practice Address - Phone:415-329-0396
Practice Address - Fax:415-239-4140
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9370101Medicaid