Provider Demographics
NPI:1790873206
Name:LEE, THOMAS MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARK
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:PO BOX1000
Mailing Address - Street 2:13681 SKYWAY
Mailing Address - City:MAGALIA
Mailing Address - State:CA
Mailing Address - Zip Code:95954
Mailing Address - Country:US
Mailing Address - Phone:530-872-8585
Mailing Address - Fax:530-872-8555
Practice Address - Street 1:13681 SKYWAY
Practice Address - Street 2:
Practice Address - City:MAGALIA
Practice Address - State:CA
Practice Address - Zip Code:95954-9749
Practice Address - Country:US
Practice Address - Phone:530-872-8585
Practice Address - Fax:530-872-8555
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28470122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist