Provider Demographics
NPI:1649336470
Name:HERMEN, LEE WARDLE (DDS)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:WARDLE
Last Name:HERMEN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:WARDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-414-1300
Mailing Address - Fax:
Practice Address - Street 1:1057 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2509
Practice Address - Country:US
Practice Address - Phone:360-414-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600130051223G0001X
WADE 60013005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1092355Medicaid