Provider Demographics
NPI:1164680831
Name:LEE, RAYMOND W (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2785
Mailing Address - Country:US
Mailing Address - Phone:317-527-0066
Mailing Address - Fax:
Practice Address - Street 1:803 EDWARDS DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2785
Practice Address - Country:US
Practice Address - Phone:317-527-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010748A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200932660Medicaid
IN200932660Medicaid