Provider Demographics
NPI:1841323672
Name:LEE, WONSEOK (DDS)
Entity type:Individual
Prefix:DR
First Name:WONSEOK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:W
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS PC
Mailing Address - Street 1:4444 W NORTHERN AVE
Mailing Address - Street 2:SUITE A3
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301
Mailing Address - Country:US
Mailing Address - Phone:623-842-1075
Mailing Address - Fax:623-931-5881
Practice Address - Street 1:4444 W NORTHERN AVE
Practice Address - Street 2:SUITE A3
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301
Practice Address - Country:US
Practice Address - Phone:623-842-1075
Practice Address - Fax:623-931-5881
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
533689OtherAETNA DENTAL
197388OtherUNITED CONCORDIA
AZ135229OtherAHCCCS
AZ0489860OtherBCBS DENTAL