Provider Demographics
NPI:1114536240
Name:LEE, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13720 OLD SAINT AUGUSTINE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-7415
Mailing Address - Country:US
Mailing Address - Phone:904-292-1002
Mailing Address - Fax:
Practice Address - Street 1:13720 OLD SAINT AUGUSTINE RD STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7415
Practice Address - Country:US
Practice Address - Phone:904-292-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24910122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist