Provider Demographics
NPI:1174691521
Name:LEE, SANGYOUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:SANGYOUNG
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 1:125 S NAPPANEE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1967
Mailing Address - Country:US
Mailing Address - Phone:574-522-0516
Mailing Address - Fax:574-294-1407
Practice Address - Street 1:125 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1967
Practice Address - Country:US
Practice Address - Phone:574-522-0516
Practice Address - Fax:574-294-1407
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN93611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100327580AMedicaid
IN351864354OtherTAX ID
IN000530461OtherUNITED CONCORDIA