Provider Demographics
NPI:1801904644
Name:LEE, DWIGHT
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540622
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0622
Mailing Address - Country:US
Mailing Address - Phone:214-505-8765
Mailing Address - Fax:972-237-1074
Practice Address - Street 1:4223 CEDAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2819
Practice Address - Country:US
Practice Address - Phone:214-505-8765
Practice Address - Fax:972-237-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1101380001Medicare NSC