Provider Demographics
NPI:1962725994
Name:TIMOTHY D. LEE, DDS, PC
Entity type:Organization
Organization Name:TIMOTHY D. LEE, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DAE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-923-0648
Mailing Address - Street 1:4021 RHEA RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2727
Mailing Address - Country:US
Mailing Address - Phone:940-613-0210
Mailing Address - Fax:940-613-0213
Practice Address - Street 1:4021 RHEA RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2727
Practice Address - Country:US
Practice Address - Phone:940-613-0210
Practice Address - Fax:940-613-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3469330-01Medicaid
TX209326201Medicaid
TX5441000Medicaid