Provider Demographics
NPI:1447772371
Name:LEE, JERRY (DMD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 BIELENBERG DR STE 205
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1715
Mailing Address - Country:US
Mailing Address - Phone:651-200-4747
Mailing Address - Fax:651-998-1009
Practice Address - Street 1:683 BIELENBERG DR STE 205
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1715
Practice Address - Country:US
Practice Address - Phone:651-200-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6972122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist