Provider Demographics
NPI:1134615339
Name:LEE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12080 N DOVE MOUNTAIN BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658-4553
Mailing Address - Country:US
Mailing Address - Phone:520-367-2742
Mailing Address - Fax:
Practice Address - Street 1:12080 N DOVE MOUNTAIN BLVD STE 140
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-4553
Practice Address - Country:US
Practice Address - Phone:520-367-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist