Provider Demographics
NPI:1679202659
Name:LEE, CARTER CONRAD (DDS)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:CONRAD
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10495 S TOWER RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49664-9787
Mailing Address - Country:US
Mailing Address - Phone:231-633-1378
Mailing Address - Fax:
Practice Address - Street 1:2360 E STADIUM BLVD STE 14
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4887
Practice Address - Country:US
Practice Address - Phone:734-677-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016012751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice