Basic Information
| Provider Information | |||||||||
| NPI: | 1932461639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | EUN JIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA ST | ||||||||
| Address2: | PO BOX 577 | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 3115 WILLIAMSON COUNTY PKWY | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189698600 | ||||||||
| FaxNumber: | 6189978978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2012 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 019029033 | IL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 019029033 | 05 | IL | MEDICAID |