Provider Demographics
NPI:1578632964
Name:LEE, JASON HARRISS
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:HARRISS
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2384
Mailing Address - Country:US
Mailing Address - Phone:706-691-2287
Mailing Address - Fax:
Practice Address - Street 1:116 DAVIS RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2384
Practice Address - Country:US
Practice Address - Phone:706-691-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42651223G0001X
GADN0134291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice