MEDICARE: DR. KENNETH LEEZER 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	019.032742	IL

General Provider Information

NPI Number	:	1457979189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH LEEZER DDS

Provider Business Mailing Address
First Line	:	2752 N SEMINARY AVE APT 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-8119
Country	:	US
Telephone Number	:	812-606-7165
Fax Number	:

Provider Business Practice Location Address
First Line	:	4317 S ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-3140
Country	:	US
Telephone Number	:	773-832-5716
Fax Number	:

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	07/09/2020

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