Individual
BRENT D LEE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S., M.S.
Contact information
Practice address
165 N 14TH AVE, POCATELLO, ID 83201-4146
(208) 232-2807
(208) 232-8118
Mailing address
PO BOX 6033, 165 N 14TH AVE, POCATELLO, ID 83205-6033
(208) 232-2807
(208) 232-8118
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
D1494
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010009592
RAILROAD
ID
01
—
6M097
BLUE CROSS
ID
Enumeration date
11/17/2006
Last updated
07/08/2007
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