MEDICARE: DR. TIMOTHY DAE LEE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	22042	TX
2	1223P0221X	Pediatric Dentistry	80	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982638359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY DAE LEE DDS

Provider Business Mailing Address
First Line	:	4021 RHEA RD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2727
Country	:	US
Telephone Number	:	214-923-0648
Fax Number	:	940-613-0213

Provider Business Practice Location Address
First Line	:	4021 RHEA RD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-2727
Country	:	US
Telephone Number	:	214-923-0648
Fax Number	:	940-613-0213

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	03/07/2016

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