Provider Demographics
NPI:1366771875
Name:LEE, JAE EUN (DDS)
Entity type:Individual
Prefix:
First Name:JAE EUN
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 1:1860 VIRGINIA AVE
Mailing Address - Street 2:#8
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2355
Mailing Address - Country:US
Mailing Address - Phone:541-756-7568
Mailing Address - Fax:541-756-0760
Practice Address - Street 1:1860 VIRGINIA AVE
Practice Address - Street 2:#8
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-2355
Practice Address - Country:US
Practice Address - Phone:541-756-7568
Practice Address - Fax:541-756-0760
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60744122300000X
ORD9736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist