Provider Demographics
NPI:1720465602
Name:LEE FAMILY DENTSTRY, LLC
Entity Type:Organization
Organization Name:LEE FAMILY DENTSTRY, LLC
Other - Org Name:FORT O SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-686-6011
Mailing Address - Street 1:138 BATTLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 BATTLEWOOD DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4006
Practice Address - Country:US
Practice Address - Phone:706-686-6011
Practice Address - Fax:706-820-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131341223G0001X
GADN0111161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000583085CMedicaid
GA076800461BMedicaid