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NPI Code Detail

MEDICARE: KENNETH LEE

MEDICARE: KENNETH LEE
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
1390200000XStudent in an Organized Health Care Education/Training ProgramIL
21223G0001XGeneral Practice Dentistry019.033918IL

General Provider Information

NPI Number : 1255064614
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH LEE
Provider Business Mailing Address
First Line : 2 BAY CLUB DR APT 16K
Second Line :
City : BAYSIDE
State : NY
Zip : 11360-2930
Country : US
Telephone Number : 347-551-4311
Fax Number :
Provider Business Practice Location Address
First Line : 3210 W 63RD ST
Second Line :
City : CHICAGO
State : IL
Zip : 60629-3325
Country : US
Telephone Number : 773-776-8300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/05/2022
Last Update Date : 08/24/2023

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Directions to “ KENNETH LEE ” Practice Location

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