Provider Demographics
NPI:1518383942
Name:LEE, MAMIE
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 HALIEGH PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4778
Mailing Address - Country:US
Mailing Address - Phone:369-430-7435
Mailing Address - Fax:
Practice Address - Street 1:3565 HALIEGH PL
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4778
Practice Address - Country:US
Practice Address - Phone:369-430-7436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00005237124Q00000X
ORH3962124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist