Provider Demographics
NPI:1558486027
Name:LEE, DAVE CHILDRESS (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVE
Middle Name:CHILDRESS
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 1:570 N JEFF DAVIS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1834
Mailing Address - Country:US
Mailing Address - Phone:770-461-6465
Mailing Address - Fax:770-461-2888
Practice Address - Street 1:570 N JEFF DAVIS DR
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1834
Practice Address - Country:US
Practice Address - Phone:770-461-6465
Practice Address - Fax:770-461-2888
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA98151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice