Healthcare Provider Details

I. General information

NPI: 1104512763
Provider Name (Legal Business Name): JENNIFER LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 BOSTON AVE
BRIDGEPORT CT
06610-1662
US

IV. Provider business mailing address

1011 WASHINGTON BLVD UNIT 601
STAMFORD CT
06901-2224
US

V. Phone/Fax

Practice location:
  • Phone: 203-873-0598
  • Fax:
Mailing address:
  • Phone: 512-554-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14789
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: