Basic Information
Provider Information
NPI: 1659679389
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: LEE
MiddleName: M.
NamePrefix: MS.
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 19842 E 39TH AVE
Address2:  
City: DENVER
State: CO
PostalCode: 802497351
CountryCode: US
TelephoneNumber: 7203740444
FaxNumber:  
Practice Location
Address1: 3551 CHAMBERS RD
Address2: SUITE A-D
City: AURORA
State: CO
PostalCode: 800111330
CountryCode: US
TelephoneNumber: 3033750649
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/03/2011
LastUpdateDate: 03/07/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X904413COY Dental ProvidersDental Hygienist 

No ID Information.


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