Provider Demographics
NPI:1295810521
Name:LEE, TED (DMD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 PLEASANT STREET
Mailing Address - Street 2:1F
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3550
Mailing Address - Country:US
Mailing Address - Phone:781-397-8876
Mailing Address - Fax:781-324-7166
Practice Address - Street 1:572 PLEASANT STREET
Practice Address - Street 2:1F
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-3550
Practice Address - Country:US
Practice Address - Phone:781-397-8876
Practice Address - Fax:781-324-7166
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16528122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0269115Medicaid