Healthcare Provider Details

I. General information

NPI: 1790916484
Provider Name (Legal Business Name): DENTISTRY AT WINDERMERE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 BUFORD HWY SUITE 200
CUMMING GA
30041-8215
US

IV. Provider business mailing address

2950 BUFORD HWY SUITE 200
CUMMING GA
30041-8215
US

V. Phone/Fax

Practice location:
  • Phone: 770-205-1212
  • Fax: 770-205-1211
Mailing address:
  • Phone: 770-205-1212
  • Fax: 770-205-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN013420
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN013473
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. BRIAN Y LEE
Title or Position: DENTIST/OWNER
Credential: D.D.S.
Phone: 770-205-1212