Provider Demographics
NPI:1730472986
Name:LEE, WILSON D (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 NW LOST SPRINGS TER
Mailing Address - Street 2:#401
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6444
Mailing Address - Country:US
Mailing Address - Phone:310-955-6546
Mailing Address - Fax:
Practice Address - Street 1:315 NW LOST SPRINGS TER
Practice Address - Street 2:#401
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6444
Practice Address - Country:US
Practice Address - Phone:310-955-6546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA606451223P0300X
ORD101801223P0300X
WADE 605673891223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program