Provider Demographics
NPI:1083828453
Name:LEE, EDWINA FAYE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MS
First Name:EDWINA
Middle Name:FAYE
Last Name:LEE
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:MRS
Other - First Name:EDWINA
Other - Middle Name:LEE
Other - Last Name:HORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DENTAL HYGIENIST
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:ACOMA CANONCITO LAGUNA INDIAN HOSPITAL DHHS IHS
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5385
Mailing Address - Fax:505-552-5473
Practice Address - Street 1:EXIT 102 OFF I40
Practice Address - Street 2:1/2 MI SOUTH
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049
Practice Address - Country:US
Practice Address - Phone:505-552-5310
Practice Address - Fax:505-552-5490
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2038124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
320070Medicare ID - Type Unspecified
PHS000Medicare UPIN