Provider Demographics
NPI:1831477520
Name:EDWARDS, LEE JOHANNA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:JOHANNA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 NORTHWEST LN SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6908
Mailing Address - Country:US
Mailing Address - Phone:360-491-4343
Mailing Address - Fax:
Practice Address - Street 1:1450 NORTHWEST LN SE
Practice Address - Street 2:SUITE C
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6908
Practice Address - Country:US
Practice Address - Phone:360-491-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60234008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist