Provider Demographics
NPI:1861567349
Name:LEE, KANG YUL (DDS)
Entity type:Individual
Prefix:DR
First Name:KANG
Middle Name:YUL
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 1:2180 LAKE TAHOE BLVD
Mailing Address - Street 2:STE #5
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-541-8229
Mailing Address - Fax:530-541-8964
Practice Address - Street 1:2180 LAKE TAHOE BLVD.
Practice Address - Street 2:STE #5
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-541-8229
Practice Address - Fax:530-541-8964
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451301223G0001X
NV4897T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91956Medicaid