Provider Demographics
NPI:1265597512
Name:LEE, FREDRIC O
Entity type:Individual
Prefix:
First Name:FREDRIC
Middle Name:O
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 VOSE AVE
Mailing Address - Street 2:APT 10
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2011
Mailing Address - Country:US
Mailing Address - Phone:973-761-0769
Mailing Address - Fax:
Practice Address - Street 1:1543 INWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-2001
Practice Address - Country:US
Practice Address - Phone:718-681-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0380ECMedicare UPIN