MEDICARE: DR. MARCUS JAMES VANDERLEEST DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	53064	WI

General Provider Information

NPI Number	:	1083722169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCUS JAMES VANDERLEEST DDS

Provider Business Mailing Address
First Line	:	2913 GLENDALE AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54313
Country	:	US
Telephone Number	:	920-434-3950
Fax Number	:

Provider Business Practice Location Address
First Line	:	2913 GLENDALE AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54313
Country	:	US
Telephone Number	:	920-434-3950
Fax Number	:	920-434-3912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	07/08/2007

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