Provider Demographics
NPI:1104091388
Name:FLEETWOOD DENTAL PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:FLEETWOOD DENTAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-944-9771
Mailing Address - Street 1:805 N RICHMOND STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522
Mailing Address - Country:US
Mailing Address - Phone:610-944-9771
Mailing Address - Fax:610-944-0702
Practice Address - Street 1:805 N RICHMOND STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522
Practice Address - Country:US
Practice Address - Phone:610-944-9771
Practice Address - Fax:610-944-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty