Provider Demographics
NPI:1821468455
Name:LEE, GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 SHADOWLAWN DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-1744
Mailing Address - Country:US
Mailing Address - Phone:201-953-2878
Mailing Address - Fax:
Practice Address - Street 1:470 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3262
Practice Address - Country:US
Practice Address - Phone:973-546-6977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02611800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist