Healthcare Provider Details

I. General information

NPI: 1003723701
Provider Name (Legal Business Name): KRISTIN LEE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3254 RED LION RD
PHILADELPHIA PA
19114-1109
US

IV. Provider business mailing address

240 S 40TH ST
PHILADELPHIA PA
19104-6030
US

V. Phone/Fax

Practice location:
  • Phone: 215-632-1612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS046059
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: