Healthcare Provider Details

I. General information

NPI: 1407594047
Provider Name (Legal Business Name): JONATHAN LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 MILLETT DR
AUBURN ME
04210-4099
US

IV. Provider business mailing address

33 DOWNEAST LANE
SCARBOROUGH ME
04074
US

V. Phone/Fax

Practice location:
  • Phone: 207-784-1577
  • Fax:
Mailing address:
  • Phone: 207-316-3406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN4960
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: