Healthcare Provider Details

I. General information

NPI: 1972585107
Provider Name (Legal Business Name): LEE E ROUNDY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649 ATTN: REVENUE GENERATION
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5529129-9923
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5529129-9921
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-194C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: