Basic Information
Provider Information | |||||||||
NPI: | 1982750055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KYUNG-LEE | ||||||||
FirstName: | YUN | ||||||||
MiddleName: | DOK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KYUNG | ||||||||
OtherFirstName: | YUN | ||||||||
OtherMiddleName: | DOK | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2518 NW PINNACLE DR | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972298000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034075872 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1933 SW JEFFERSON ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972012405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032738240 | ||||||||
FaxNumber: | 5032284944 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2007 | ||||||||
LastUpdateDate: | 03/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D7174 | OR | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.