Provider Demographics
NPI:1548463425
Name:LEE, SUR (DDS)
Entity type:Individual
Prefix:
First Name:SUR
Middle Name:
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 1:5227 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-1008
Mailing Address - Country:US
Mailing Address - Phone:201-783-3168
Mailing Address - Fax:
Practice Address - Street 1:2535 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-4648
Practice Address - Country:US
Practice Address - Phone:718-365-4900
Practice Address - Fax:516-822-2396
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046420-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01653158Medicaid