Provider Demographics
NPI:1194964262
Name:LEE, JENSEN JASON (DMD)
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:JASON
Last Name:LEE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N PARK VICTORIA DR
Mailing Address - Street 2:#B
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-4600
Mailing Address - Country:US
Mailing Address - Phone:408-586-9663
Mailing Address - Fax:408-824-5001
Practice Address - Street 1:40 N PARK VICTORIA DR
Practice Address - Street 2:#B
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-4600
Practice Address - Country:US
Practice Address - Phone:408-586-9663
Practice Address - Fax:408-824-5001
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist