Basic Information
| Provider Information | |||||||||
| NPI: | 1942761648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | CLARA | ||||||||
| MiddleName: | TAEYOON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 CRESCENT ST APT 1810 | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479211098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 82-68 164TH ST | ||||||||
| Address2: | N BUILDING ROOM 633 | ||||||||
| City: | QUEENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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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 | NA | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | NA | 01 | NA | OTHER |