Provider Demographics
NPI:1679634190
Name:LEE, BRANDON S (DMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:S
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 1:5853 JARVIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-1251
Mailing Address - Country:US
Mailing Address - Phone:503-547-9996
Mailing Address - Fax:
Practice Address - Street 1:5853 JARVIS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1251
Practice Address - Country:US
Practice Address - Phone:503-547-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR88431223G0001X
ORD88431223G0001X
CADDS1088531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice