MEDICARE: DR. SUSAN LEE D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	009701	CT

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

General Provider Information

NPI Number	:	1780887281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN LEE D.D.S.

Provider Business Mailing Address
First Line	:	323 MAIN STREET
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-1638
Country	:	US
Telephone Number	:	203-937-7181
Fax Number	:	203-937-1940

Provider Business Practice Location Address
First Line	:	323 MAIN ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4424
Country	:	US
Telephone Number	:	203-937-7181
Fax Number	:	203-937-1940

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	12/20/2013

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