Provider Demographics
NPI:1225680531
Name:LEE, SUN JOO
Entity type:Individual
Prefix:
First Name:SUN
Middle Name:JOO
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FORT HILL RD APT 112
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2266
Mailing Address - Country:US
Mailing Address - Phone:804-426-9264
Mailing Address - Fax:
Practice Address - Street 1:939 NY-376 #1
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590
Practice Address - Country:US
Practice Address - Phone:845-223-9987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL68351223G0001X
NY63747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice