Provider Demographics
NPI:1679295992
Name:LEE, BRIAN SANGHWAN (DMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SANGHWAN
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 TOWN AND FOUR PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6225
Mailing Address - Country:US
Mailing Address - Phone:661-526-9001
Mailing Address - Fax:
Practice Address - Street 1:10000 WATSON RD STE 2MM
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1848
Practice Address - Country:US
Practice Address - Phone:314-435-4204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240035021223G0001X
NV77041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice