MEDICARE: COLLEEN LEE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	058518	NY
2	1223G0001X	General Practice Dentistry	DE60778730	WA
3	122300000X	Dentist	30.026298	OH

General Provider Information

NPI Number	:	1083001945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN LEE DDS

Provider Business Mailing Address
First Line	:	3636 MAYFIELD RD STE J-14
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-1403
Country	:	US
Telephone Number	:	216-220-0238
Fax Number	:

Provider Business Practice Location Address
First Line	:	3636 MAYFIELD RD STE J-14
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-1403
Country	:	US
Telephone Number	:	216-220-0238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2015
Last Update Date	:	06/21/2021

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