Provider Demographics
NPI:1174543847
Name:LEE, JACOB J (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
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 1:1006 PROFESSIONAL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-226-2228
Mailing Address - Fax:706-226-1881
Practice Address - Street 1:1006 PROFESSIONAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2505
Practice Address - Country:US
Practice Address - Phone:706-226-2228
Practice Address - Fax:706-226-1881
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0131341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2399375OtherTIN