Healthcare Provider Details

I. General information

NPI: 1386165249
Provider Name (Legal Business Name): DR. ANGELA DEANN LEE ,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 POWERS PL
ALPHARETTA GA
30009-8356
US

IV. Provider business mailing address

959 BRIDGEGATE DR NE
MARIETTA GA
30068-2206
US

V. Phone/Fax

Practice location:
  • Phone: 770-712-9125
  • Fax:
Mailing address:
  • Phone: 770-712-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1284
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1284
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1284
License Number StateGA

VIII. Authorized Official

Name: DR. ANGELA DEANN LEE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 770-712-9125