Basic Information
Provider Information | |||||||||
NPI: | 1134675689 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | WENDY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 398 192ND ARMOR TANK BATTALION RD | ||||||||
Address2: | USA DENTAC HQS BLDG 1022 | ||||||||
City: | FORT KNOX | ||||||||
State: | KY | ||||||||
PostalCode: | 401215116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026246158 | ||||||||
FaxNumber: | 5026242966 | ||||||||
Practice Location | |||||||||
Address1: | 289 IRELAND AVE | ||||||||
Address2: | HOSPITAL DENTAL CLINIC BLDG 851 | ||||||||
City: | FORT KNOX | ||||||||
State: | KY | ||||||||
PostalCode: | 401215111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026249670 | ||||||||
FaxNumber: | 5026249778 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2016 | ||||||||
LastUpdateDate: | 08/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 3648 | KY | Y |   | Dental Providers | Dental Hygienist |   |
No ID Information.