Provider Demographics
NPI:1679748339
Name:LEE, SOPHIA Y (DMD)
Entity type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:Y
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WEST MAIN STREET
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052
Mailing Address - Country:US
Mailing Address - Phone:856-779-8777
Mailing Address - Fax:
Practice Address - Street 1:60 WEST MAIN STREET
Practice Address - Street 2:SUITE 1A
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052
Practice Address - Country:US
Practice Address - Phone:856-779-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02207300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist