Provider Demographics
NPI:1699905521
Name:LEE, MOONYOUNG (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MOONYOUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EVERETT AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2374
Mailing Address - Country:US
Mailing Address - Phone:617-389-2112
Mailing Address - Fax:
Practice Address - Street 1:100 EVERETT AVE STE 10
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2374
Practice Address - Country:US
Practice Address - Phone:617-389-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18551641223X0400X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1427484062Medicaid