Provider Demographics
NPI:1689870768
Name:LEE, GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 PROVIDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4326
Mailing Address - Country:US
Mailing Address - Phone:931-648-4100
Mailing Address - Fax:
Practice Address - Street 1:304 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:931-648-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029781Medicaid