Provider Demographics
NPI:1912311234
Name:LEE, THEODORE TAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:TAK
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:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0212
Mailing Address - Country:US
Mailing Address - Phone:360-377-3776
Mailing Address - Fax:
Practice Address - Street 1:616 6TH ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1420
Practice Address - Country:US
Practice Address - Phone:360-377-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-14
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60477328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist