Provider Demographics
NPI:1093000150
Name:LEE, SPENCER MATTHEW (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:MATTHEW
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG/SGHJ
Mailing Address - Street 2:4881 SUGAR MAPLE DR.
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-9610
Mailing Address - Fax:
Practice Address - Street 1:88 MDG/SGHJ
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8197122300000X
AZD0081971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist