Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223E0200X | Endodontist | 64396 | CA |
Y | 1223E0200X | Endodontist | RFD000014 | PA |
NPI | 1033564935 |
---|---|
Provider Name | Dr. Su-Min Lee |
First Address | Philadelphia, PA 19107-4140 |
Second Address | Philadelphia, PA 19104-6030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2016 |
Last Update Date | 28/04/2016 |