Provider Demographics
NPI:1154495802
Name:LEE, BRENT D (DDS, MS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6033
Mailing Address - Street 2:165 N 14TH AVE
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-6033
Mailing Address - Country:US
Mailing Address - Phone:208-232-2807
Mailing Address - Fax:208-232-8118
Practice Address - Street 1:165 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4146
Practice Address - Country:US
Practice Address - Phone:208-232-2807
Practice Address - Fax:208-232-8118
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD14941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010009592OtherRAILROAD
ID6M097OtherBLUE CROSS
ID6M097OtherBLUE CROSS
IDT44220Medicare UPIN