Provider Demographics
NPI:1003038928
Name:LEE, FRED MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:MATTHEW
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6709 MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-2219
Mailing Address - Country:US
Mailing Address - Phone:301-365-7005
Mailing Address - Fax:
Practice Address - Street 1:650 W BALTIMORE ST STE 6402
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1510
Practice Address - Country:US
Practice Address - Phone:410-706-7461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010083171223G0001X
DCDEN42361223G0001X
MD85171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC016891200Medicaid