Provider Demographics
NPI:1144432469
Name:DAVID BLONG S LEE DDS SC
Entity type:Organization
Organization Name:DAVID BLONG S LEE DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID BLONG
Authorized Official - Middle Name:SHONANOU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-459-9010
Mailing Address - Street 1:825 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SEHBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-459-9010
Mailing Address - Fax:920-459-9272
Practice Address - Street 1:825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-459-9010
Practice Address - Fax:920-459-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33757100Medicaid