Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 0401411230 | VA |
NPI | 1104048552 |
---|---|
Provider Name | Dr. Brian Lee |
First Address | Fairfax, VA 22031-3757 |
Second Address | Fairfax, VA 22031-3757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 08/07/2007 |