Provider Demographics
NPI:1871642827
Name:LEE, BURGESS HERBERT JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:BURGESS
Middle Name:HERBERT
Last Name:LEE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BUDDY
Other - Middle Name:HERBERT
Other - Last Name:LEE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5705
Practice Address - Fax:912-435-9385
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO102251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice