1740352608 NPI number — LEE D JESS DDS LTD

Table of content: (NPI 1740352608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740352608 NPI number — LEE D JESS DDS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE D JESS DDS LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740352608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S POKEGAMA AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-326-3231
Provider Business Mailing Address Fax Number:
218-326-4619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S POKEGAMA AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-326-3231
Provider Business Practice Location Address Fax Number:
218-326-4619
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JESS
Authorized Official First Name:
LEE
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
218-326-3231

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  7035 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 038015600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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