Provider Demographics
NPI:1386759678
Name:THELEN, LEE P
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:P
Last Name:THELEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 ORCA DR NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-1945
Mailing Address - Country:US
Mailing Address - Phone:253-927-8843
Mailing Address - Fax:
Practice Address - Street 1:33801 1ST WAY S
Practice Address - Street 2:#361
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4546
Practice Address - Country:US
Practice Address - Phone:253-838-4200
Practice Address - Fax:253-838-4014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WATH2653OtherREGENCE BLUE SHIELD
WA654977OtherUNITED CONCORDIA