Provider Demographics
NPI:1679267660
Name:LEE, TRAVIS (DDS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 10TH AVE S STE 2
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-3267
Mailing Address - Country:US
Mailing Address - Phone:406-453-6467
Mailing Address - Fax:
Practice Address - Street 1:2817 10TH AVE S STE 2
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-3267
Practice Address - Country:US
Practice Address - Phone:406-453-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-25992122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist