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General NPI Number Information
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NPI Number | 1912438805
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Entity Type | Individual
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Provider Name | JACOB LEE DMD, MD
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Gender | Male
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 08/09/2023
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Provider Practice Location Address
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Address Line | 1260 HIGHWAY 54 STE 200
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4513
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Country | US
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Telephone | 770-461-2101
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Fax |
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Provider Business Mailing Address
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Address Line | 2593 BROOKLINE CIR NE
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City | BROOKHAVEN
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State | GA
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Zip | 30319-3691
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Country | US
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Telephone | 404-966-8576
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 94785
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN122602
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License Number State | GA
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