Provider Demographics
NPI:1821026907
Name:LEE, JESSE G
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:G
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-3807
Mailing Address - Country:US
Mailing Address - Phone:910-892-2137
Mailing Address - Fax:910-892-2546
Practice Address - Street 1:210 N ELLIS AVE
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-3807
Practice Address - Country:US
Practice Address - Phone:910-892-2137
Practice Address - Fax:910-892-2546
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC95206OtherBCBS
NC8995206Medicaid