Provider Demographics
NPI:1710140116
Name:JOHN H LEE DMD PC
Entity Type:Organization
Organization Name:JOHN H LEE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-724-7575
Mailing Address - Street 1:80 MAPLE AVENUE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-724-7575
Mailing Address - Fax:631-724-4790
Practice Address - Street 1:80 MAPLE AVENUE
Practice Address - Street 2:SUITE 208
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-724-7575
Practice Address - Fax:631-724-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0503811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02602528Medicaid