Provider Demographics
NPI:1598213811
Name:JIMMIE LEE DENTAL LLC
Entity Type:Organization
Organization Name:JIMMIE LEE DENTAL LLC
Other - Org Name:VOORHEES DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-753-2900
Mailing Address - Street 1:180 ROUTE 73
Mailing Address - Street 2:SUITE 1202
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9546
Mailing Address - Country:US
Mailing Address - Phone:856-753-2900
Mailing Address - Fax:856-753-5151
Practice Address - Street 1:180 ROUTE 73
Practice Address - Street 2:SUITE 1202
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9546
Practice Address - Country:US
Practice Address - Phone:856-753-2900
Practice Address - Fax:856-753-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025551001223G0001X
NJ22DI010467001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0328651Medicaid
NJ0469947Medicaid