Provider Demographics
NPI:1720195472
Name:DODSON, LEE CHANDLER
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:CHANDLER
Last Name:DODSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 N PARK BLVD
Mailing Address - Street 2:SUIT 107
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6981
Mailing Address - Country:US
Mailing Address - Phone:817-481-1036
Mailing Address - Fax:817-481-5044
Practice Address - Street 1:230 N PARK BLVD
Practice Address - Street 2:SUIT 107
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6981
Practice Address - Country:US
Practice Address - Phone:817-481-1036
Practice Address - Fax:817-481-5044
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice