Provider Demographics
NPI:1326108754
Name:LEE, PETRA G (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:G
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 1:609 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3211
Mailing Address - Country:US
Mailing Address - Phone:352-796-2034
Mailing Address - Fax:888-581-9789
Practice Address - Street 1:609 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-796-2034
Practice Address - Fax:888-581-9789
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN176271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice