Provider Demographics
NPI:1285846592
Name:LEE, DAVID BLONG SHOUANOU (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAVID BLONG
Middle Name:SHOUANOU
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 1:4925 STONEFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083
Mailing Address - Country:US
Mailing Address - Phone:920-459-9010
Mailing Address - Fax:920-459-9272
Practice Address - Street 1:825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-459-9010
Practice Address - Fax:920-459-9272
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33757100Medicaid