Provider Demographics
NPI:1164497319
Name:LEE, JAI GOO (DDS)
Entity type:Individual
Prefix:DR
First Name:JAI
Middle Name:GOO
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:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8383
Mailing Address - Fax:707-263-5019
Practice Address - Street 1:925 BEVINS COURT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD86601223G0001X
CA103634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBL9515466OtherDEA