Healthcare Provider Details

I. General information

NPI: 1528821998
Provider Name (Legal Business Name): KELLIE K LEE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 BROAD AVE STE 202
RIDGEFIELD NJ
07657-1604
US

IV. Provider business mailing address

200 BOYDEN AVE APT 336
MAPLEWOOD NJ
07040-2596
US

V. Phone/Fax

Practice location:
  • Phone: 201-224-9968
  • Fax:
Mailing address:
  • Phone: 916-838-3237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number113017
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02988000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: