Provider Demographics
NPI:1790395200
Name:LEE, SAMANTHA (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 UNION RD
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-9776
Mailing Address - Country:US
Mailing Address - Phone:574-339-8626
Mailing Address - Fax:
Practice Address - Street 1:125 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1967
Practice Address - Country:US
Practice Address - Phone:574-522-0156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013433A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist