Provider Demographics
NPI:1649322546
Name:LEE, JOHN HSUEH JEN LIAO (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HSUEH JEN LIAO
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:PO BOX 610005
Mailing Address - Street 2:
Mailing Address - City:NEWTON HIGHLANDS
Mailing Address - State:MA
Mailing Address - Zip Code:02461-0005
Mailing Address - Country:US
Mailing Address - Phone:617-965-5967
Mailing Address - Fax:617-965-5967
Practice Address - Street 1:1250 HANCOCK STREET
Practice Address - Street 2:SUITE 123
Practice Address - City:QUINCY CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02169-4339
Practice Address - Country:US
Practice Address - Phone:617-471-8161
Practice Address - Fax:617-471-8181
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18489122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11958OtherBCBS