Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 056100-1 | NY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 265566-1 | NY |
NPI | 1366604829 |
---|---|
Provider Name | Mimi Joonyoung Lee |
First Address | Hicksville, NY 11801-5832 |
Second Address | New York, NY 10032-1565 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2008 |
Last Update Date | 25/02/2016 |