Provider Demographics
NPI:1972656338
Name:LEE, ANGIE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 OAK PARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-999-5126
Mailing Address - Fax:970-999-5928
Practice Address - Street 1:1220 OAK PARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-999-5126
Practice Address - Fax:970-999-5928
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82771223G0001X
MI2901020133122300000X
MADN18557251223P0300X
CODEN002019441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905031Medicaid