Provider Demographics
NPI:1518451103
Name:LEE, SOO JIN (DMD)
Entity type:Individual
Prefix:DR
First Name:SOO JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 BEACON ST APT 706
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4712
Mailing Address - Country:US
Mailing Address - Phone:678-677-1578
Mailing Address - Fax:
Practice Address - Street 1:1318 BEACON ST STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:857-858-0246
Practice Address - Fax:857-858-0345
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN100001841223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial PainGroup - Single Specialty