Provider Demographics
NPI:1477115061
Name:LEE, MEENA PARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEENA
Middle Name:PARK
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 1:2922 SPRING MOSS LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-4620
Mailing Address - Country:US
Mailing Address - Phone:919-200-3206
Mailing Address - Fax:
Practice Address - Street 1:15 RAWLS CHURCH RD
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501
Practice Address - Country:US
Practice Address - Phone:919-639-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist