Provider Demographics
NPI:1902459969
Name:LEE, SANG JOON (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANG JOON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6238
Mailing Address - Country:US
Mailing Address - Phone:207-784-5769
Mailing Address - Fax:
Practice Address - Street 1:480 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6238
Practice Address - Country:US
Practice Address - Phone:207-784-5769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN47311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice