Provider Demographics
NPI:1881742526
Name:LEE, BENNET S (DMD, MS)
Entity type:Individual
Prefix:
First Name:BENNET
Middle Name:S
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 N ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1259
Mailing Address - Country:US
Mailing Address - Phone:714-871-5691
Mailing Address - Fax:714-871-5691
Practice Address - Street 1:2050 N ACACIA AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1259
Practice Address - Country:US
Practice Address - Phone:714-871-5691
Practice Address - Fax:714-871-5691
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213241223G0001X
CA599261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0205109Medicaid