Provider Demographics
NPI:1912438805
Name:LEE, JACOB (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 BROOKLINE CIR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3691
Mailing Address - Country:US
Mailing Address - Phone:404-966-8576
Mailing Address - Fax:
Practice Address - Street 1:1260 HIGHWAY 54 STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4513
Practice Address - Country:US
Practice Address - Phone:770-461-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA94785204E00000X
GADN1226021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery