Provider Demographics
NPI:1134123524
Name:WHITESIDES, LEE MCLEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:MCLEAN
Last Name:WHITESIDES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 LAKE OCONEE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9510
Mailing Address - Country:US
Mailing Address - Phone:706-916-4764
Mailing Address - Fax:706-454-0088
Practice Address - Street 1:1097 LAKE OCONEE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9510
Practice Address - Country:US
Practice Address - Phone:706-916-4764
Practice Address - Fax:706-454-0088
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0011231223S0112X
GADNO11123204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU66815Medicare UPIN
GA10NCBZLMedicare ID - Type Unspecified
10NCBZLMedicare PIN