Provider Demographics
NPI:1962714139
Name:LEE, SHAWN D (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:D
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 1:5398 N LANGE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6228
Mailing Address - Country:US
Mailing Address - Phone:208-371-5132
Mailing Address - Fax:
Practice Address - Street 1:2811 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8482
Practice Address - Country:US
Practice Address - Phone:208-466-2458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-43031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice