Provider Demographics
NPI:1790905495
Name:LEE, BRYAN D (DDS, MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-5959
Mailing Address - Fax:208-356-5559
Practice Address - Street 1:360 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-5959
Practice Address - Fax:208-356-5559
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2015-05-29
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-16
Provider Licenses
StateLicense IDTaxonomies
IDD-35421223G0001X
IDD-3542-OS1223S0112X
IDM-11482204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806068200Medicaid