Provider Demographics
NPI:1255487112
Name:LEE, JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:19316 NORTHERN BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2900
Mailing Address - Country:US
Mailing Address - Phone:347-438-1000
Mailing Address - Fax:347-438-1002
Practice Address - Street 1:24536 76TH AVE # A
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1802
Practice Address - Country:US
Practice Address - Phone:718-772-3465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052270-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02691909Medicaid