Healthcare Provider Details

I. General information

NPI: 1164417267
Provider Name (Legal Business Name): JOHN S LEE DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 05/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S DENTON TAP RD STE 200
COPPELL TX
75019-4539
US

IV. Provider business mailing address

600 S DENTON TAP RD STE 200
COPPELL TX
75019-4539
US

V. Phone/Fax

Practice location:
  • Phone: 972-471-0647
  • Fax:
Mailing address:
  • Phone: 972-471-0647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number23777
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019436
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02264400
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035851
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: