Provider Demographics
NPI:1336461284
Name:LEE, TIM (DDS)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 HUTLEY WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95746-7161
Mailing Address - Country:US
Mailing Address - Phone:504-202-7789
Mailing Address - Fax:
Practice Address - Street 1:9450 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3588
Practice Address - Country:US
Practice Address - Phone:504-202-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS639531223S0112X
390200000X
LAS-6221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program