Provider Demographics
NPI:1740354810
Name:LEE, PEERANAN S (DMD)
Entity type:Individual
Prefix:
First Name:PEERANAN
Middle Name:S
Last Name:LEE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:PEERANAN
Other - Middle Name:J
Other - Last Name:SONGLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2041 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5147
Mailing Address - Country:US
Mailing Address - Phone:336-777-0303
Mailing Address - Fax:336-777-3448
Practice Address - Street 1:900 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-7918
Practice Address - Country:US
Practice Address - Phone:336-370-1112
Practice Address - Fax:336-544-0739
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA427781223G0001X
KY69961223G0001X
NC83181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905460Medicaid
903AGOtherBLUE CROSS BLUE SHIELD NC