=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649284134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROLLYN PAUL LEE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 06/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 RIVER PLACE DRIVE 106
-----------------------------------------------------
City | AMERY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54001-0106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-268-2103
-----------------------------------------------------
Fax | 715-268-7729
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 106 1030 RIVER PLACE DRIVE
-----------------------------------------------------
City | AMERY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-268-2103
-----------------------------------------------------
Fax | 715-268-7729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4876015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D9794
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------