=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689622565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA J LEE D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 429 SW 153RD ST.
-----------------------------------------------------
City | BURIEN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-243-3300
-----------------------------------------------------
Fax | 206-243-7500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 429 SW 153RD ST.
-----------------------------------------------------
City | BURIEN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-243-3300
-----------------------------------------------------
Fax | 206-243-7500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DE00007590
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------