Provider Demographics
NPI:1861765836
Name:LEE, RAND A
Entity type:Individual
Prefix:DR
First Name:RAND
Middle Name:A
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4443
Mailing Address - Country:US
Mailing Address - Phone:262-694-6055
Mailing Address - Fax:262-694-9818
Practice Address - Street 1:3103 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4443
Practice Address - Country:US
Practice Address - Phone:262-694-6055
Practice Address - Fax:262-694-9818
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist