Provider Demographics
NPI:1629164462
Name:LEE, DAVID R (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:LEE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 AQUILA DR N STE 825
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3798
Mailing Address - Country:US
Mailing Address - Phone:763-323-3456
Mailing Address - Fax:763-323-9922
Practice Address - Street 1:11350 AQUILA DR N STE 825
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3798
Practice Address - Country:US
Practice Address - Phone:763-323-3456
Practice Address - Fax:763-323-9922
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU80380Medicare UPIN