MEDICARE: LESLIE LEE RDH

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	124Q00000X	Dental Hygienist	DH.905037	CO

General Provider Information

NPI Number	:	1790211969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE LEE RDH

Provider Business Mailing Address
First Line	:	3133 BROADMOOR VALLEY RD UNIT C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-660-8054
Fax Number	:

Provider Business Practice Location Address
First Line	:	6514 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-387-4385
Fax Number	:

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

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	05/10/2017

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