Provider Demographics
NPI:1780880930
Name:LEE, STEVEN B (DDS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:B
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 1:1320 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5844
Mailing Address - Country:US
Mailing Address - Phone:260-471-1222
Mailing Address - Fax:260-471-1724
Practice Address - Street 1:1320 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5844
Practice Address - Country:US
Practice Address - Phone:260-471-1222
Practice Address - Fax:260-471-1724
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120088031223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
INBLUE CROSS BLUE SHIEOther000000373783
IN191100Medicare ID - Type Unspecified