Provider Demographics
NPI:1528821998
Name:LEE, KELLIE K (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BOYDEN AVE APT 336
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2596
Mailing Address - Country:US
Mailing Address - Phone:916-838-3237
Mailing Address - Fax:
Practice Address - Street 1:605 BROAD AVE STE 202
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1604
Practice Address - Country:US
Practice Address - Phone:201-224-9968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02988000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist