Provider Demographics
NPI:1962173583
Name:LEE, GAEUN (DDS)
Entity type:Individual
Prefix:DR
First Name:GAEUN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 VERDUGO BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1419
Mailing Address - Country:US
Mailing Address - Phone:915-472-3223
Mailing Address - Fax:
Practice Address - Street 1:1809 VERDUGO BLVD STE 270
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1419
Practice Address - Country:US
Practice Address - Phone:818-952-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859278122300000X
CADDS1069891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty