Provider Demographics
NPI:1114658242
Name:LEE, MICHAEL LAWRENCE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 EDWARDS PLACE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1552
Mailing Address - Country:US
Mailing Address - Phone:314-640-8818
Mailing Address - Fax:
Practice Address - Street 1:1002 SCHROEDER CREEK BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3558
Practice Address - Country:US
Practice Address - Phone:314-900-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220121491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty