Provider Demographics
NPI:1053325795
Name:VANDEWATER, LEE CHRISTOPHER (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:CHRISTOPHER
Last Name:VANDEWATER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-422-7630
Mailing Address - Fax:770-422-6017
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 140
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-422-7630
Practice Address - Fax:770-422-6017
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0113161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00672548BMedicaid
GA00672548BMedicaid
GA19NCBSHMedicare ID - Type Unspecified