Healthcare Provider Details

I. General information

NPI: 1336116912
Provider Name (Legal Business Name): LESLIE ROBERT FISH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W WARNER RD SUITE #3
CHANDLER AZ
85224-2758
US

IV. Provider business mailing address

1200 W WARNER RD SUITE #3
CHANDLER AZ
85224-2758
US

V. Phone/Fax

Practice location:
  • Phone: 480-726-6600
  • Fax: 480-726-6611
Mailing address:
  • Phone: 480-726-6600
  • Fax: 480-726-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2835
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2835
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: