Provider Demographics
NPI:1699189431
Name:LEE, JUDYTH GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUDYTH
Middle Name:GRACE
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 1:353 KING ST APT 507
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-1680
Mailing Address - Country:US
Mailing Address - Phone:706-988-2187
Mailing Address - Fax:
Practice Address - Street 1:430 N EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-727-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026381001223P0221X
NY0586741223P0221X
CADDS1033761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid