Provider Demographics
NPI:1346727526
Name:LEE, JASON M
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24570 STEWART ST APT 19
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2727
Mailing Address - Country:US
Mailing Address - Phone:303-880-5965
Mailing Address - Fax:
Practice Address - Street 1:72333 HIGHWAY 111 STE B
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2790
Practice Address - Country:US
Practice Address - Phone:760-674-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1027451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice