MEDICARE: LEE FAMILY DENTSTRY, LLC

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	1223G0001X	General Practice Dentistry	DN011116	GA
2	1223G0001X	General Practice Dentistry	DN013134	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720465602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEE FAMILY DENTSTRY, LLC

Provider Business Mailing Address
First Line	:	138 BATTLEWOOD DR
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-4006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	138 BATTLEWOOD DR
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-4006
Country	:	US
Telephone Number	:	706-686-6011
Fax Number	:	706-820-6854

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACOB LEE
Credential	:	DDS
Telephone Number	:	706-686-6011

Provider Enumeration Date	:	04/30/2015
Last Update Date	:	04/30/2015

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