Provider Demographics
NPI:1386855948
Name:LEE, DWAYNE (LAC)
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6151 VERDA LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6931
Mailing Address - Country:US
Mailing Address - Phone:760-390-6848
Mailing Address - Fax:
Practice Address - Street 1:1219 CAMINO DEL MAR
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2505
Practice Address - Country:US
Practice Address - Phone:858-793-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10136171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10136OtherCA STATE BOARD LICENSE NUMBER