Provider Demographics
NPI:1174669170
Name:LEE, CHARLOTTE O (DMD)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:O
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2439
Mailing Address - Country:US
Mailing Address - Phone:201-894-0777
Mailing Address - Fax:201-894-0775
Practice Address - Street 1:105 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626
Practice Address - Country:US
Practice Address - Phone:201-894-0777
Practice Address - Fax:201-894-0775
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ15761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1838202Medicaid