Provider Demographics
NPI:1497056378
Name:LEE, RICHARD WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
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 1:330 3RD AVE
Mailing Address - Street 2:APT 20L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3705
Mailing Address - Country:US
Mailing Address - Phone:917-215-5172
Mailing Address - Fax:
Practice Address - Street 1:4422 THIRD AVENUE
Practice Address - Street 2:ST BARNABAS HOSPITAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:917-215-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024571001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131740122OtherEIN