Provider Demographics
NPI:1366604829
Name:LEE, MIMI JOONYOUNG (DDS, MD)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:JOONYOUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:JOONYOUNG
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MD
Mailing Address - Street 1:10 HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5832
Mailing Address - Country:US
Mailing Address - Phone:917-903-7345
Mailing Address - Fax:
Practice Address - Street 1:3915 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1565
Practice Address - Country:US
Practice Address - Phone:212-567-5536
Practice Address - Fax:212-202-6447
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056100-11223S0112X
NY265566-1204E00000X
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program