Basic Information
| Provider Information | |||||||||
| NPI: | 1174193122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | LILLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 618 DENTAL CO/US ARMY DENTAC-KOREA | ||||||||
| Address2: | UNIT 15652 | ||||||||
| City: | APO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 96271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684029 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 618 DENTAL CO/US ARMY DENTAC-KOREA | ||||||||
| Address2: | UNIT 15652 | ||||||||
| City: | APO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 96271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684029 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2021 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12335390-9921 | UT | Y | Dental Providers | Dentist | General Practice |
No ID Information.