Provider Demographics
NPI:1144361627
Name:LEE, MICKY (DDS)
Entity type:Individual
Prefix:DR
First Name:MICKY
Middle Name:
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 1:633 W HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-5601
Mailing Address - Country:US
Mailing Address - Phone:408-736-6779
Mailing Address - Fax:408-774-2356
Practice Address - Street 1:633 W HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-5601
Practice Address - Country:US
Practice Address - Phone:408-736-6779
Practice Address - Fax:408-774-2356
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB-40650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist