Provider Demographics
NPI:1790789626
Name:LEE, JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
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 1:1901 S CEDAR ST
Mailing Address - Street 2:STE 106
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2302
Mailing Address - Country:US
Mailing Address - Phone:253-272-2605
Mailing Address - Fax:
Practice Address - Street 1:1901 S CEDAR ST
Practice Address - Street 2:STE 106
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2302
Practice Address - Country:US
Practice Address - Phone:253-272-2605
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE87221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5034632Medicare ID - Type Unspecified