Provider Demographics
NPI:1811215122
Name:LEE, GENE S (DDS)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:S
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 1:609 CABRAL CIRCLE
Mailing Address - Street 2:#4207
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:510-847-0161
Mailing Address - Fax:
Practice Address - Street 1:325 ADAMS DR.
Practice Address - Street 2:SUITE 335
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086
Practice Address - Country:US
Practice Address - Phone:817-594-5888
Practice Address - Fax:817-594-6266
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27442122300000X
HIDT-24011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice