Healthcare Provider Details

I. General information

NPI: 1285645432
Provider Name (Legal Business Name): JETSON SCOTT LEE D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 20TH AVE SUITE 201
SAN FRANCISCO CA
94121-2221
US

IV. Provider business mailing address

380 20TH AVE SUITE 201
SAN FRANCISCO CA
94121-2221
US

V. Phone/Fax

Practice location:
  • Phone: 415-752-8330
  • Fax: 415-752-8333
Mailing address:
  • Phone: 415-752-8330
  • Fax: 415-752-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number032870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: