Provider Demographics
NPI:1356487748
Name:LEE, ROGER S (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:S
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 1:3440 CONWAY BLVD
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-7000
Mailing Address - Country:US
Mailing Address - Phone:941-743-4425
Mailing Address - Fax:941-743-2005
Practice Address - Street 1:3440 CONWAY BLVD
Practice Address - Street 2:SUITE 2D
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7000
Practice Address - Country:US
Practice Address - Phone:941-743-4425
Practice Address - Fax:941-743-2005
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN111121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84431Medicare UPIN