Provider Demographics
NPI:1902441488
Name:LEE, MICHELLE M (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:LEE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2330
Mailing Address - Country:US
Mailing Address - Phone:607-283-1605
Mailing Address - Fax:
Practice Address - Street 1:1025 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3629
Practice Address - Country:US
Practice Address - Phone:607-272-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019304124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist