MEDICARE: LEONID BANCHIK DMD

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	10898	NC

General Provider Information

NPI Number	:	1558450965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONID BANCHIK DMD

Provider Business Mailing Address
First Line	:	9400 S EASTERN AVE
Second Line	:	101
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-7936
Country	:	US
Telephone Number	:	702-456-0009
Fax Number	:	702-458-0009

Provider Business Practice Location Address
First Line	:	6708 ALBEMARLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-3856
Country	:	US
Telephone Number	:	704-537-1990
Fax Number	:

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	09/18/2018

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