MEDICARE: FREDRIC O 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
1	122300000X	Dentist	041217	NY

General Provider Information

NPI Number	:	1265597512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDRIC O LEE

Provider Business Mailing Address
First Line	:	107 VOSE AVE
Second Line	:	APT 10
City	:	SOUTH ORANGE
State	:	NJ
Zip	:	07079-2011
Country	:	US
Telephone Number	:	973-761-0769
Fax Number	:

Provider Business Practice Location Address
First Line	:	1543 INWOOD AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10452-2001
Country	:	US
Telephone Number	:	718-681-8700
Fax Number	:

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	09/14/2011

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Directions to “ FREDRIC O LEE ” Practice Location

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