Provider Demographics
NPI:1528112257
Name:LEE, JASON S (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 E FOOTHILL BLVD
Mailing Address - Street 2:UNIT 240
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4049
Mailing Address - Country:US
Mailing Address - Phone:909-981-6882
Mailing Address - Fax:909-981-0276
Practice Address - Street 1:1183 E FOOTHILL BLVD
Practice Address - Street 2:UNIT 240
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4049
Practice Address - Country:US
Practice Address - Phone:909-981-6882
Practice Address - Fax:909-981-0276
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA473861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47386Medicaid