Provider Demographics
NPI:1730213760
Name:LEE, TRUSTEN POLK III (DDS)
Entity type:Individual
Prefix:DR
First Name:TRUSTEN
Middle Name:POLK
Last Name:LEE
Suffix:III
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 1:8119 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-7719
Mailing Address - Country:US
Mailing Address - Phone:765-344-0642
Mailing Address - Fax:765-344-1942
Practice Address - Street 1:8119 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-7719
Practice Address - Country:US
Practice Address - Phone:765-344-0642
Practice Address - Fax:765-344-1942
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007566A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice