Healthcare Provider Details

I. General information

NPI: 1790541787
Provider Name (Legal Business Name): JEFFREY LEE LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26812 MAPLE VALLEY BLACK DIAMOND RD SE
MAPLE VALLEY WA
98038-8309
US

IV. Provider business mailing address

26812 BLACK DIAMOND RD SE
MAPLE VALLEY WA
98038-8309
US

V. Phone/Fax

Practice location:
  • Phone: 425-432-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDENT.DE.70110724
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: