Healthcare Provider Details

I. General information

NPI: 1750330916
Provider Name (Legal Business Name): KRISTIN NICOLE LEIS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 E BELL RD SUITE 1
SCOTTSDALE AZ
85254-6452
US

IV. Provider business mailing address

1575 BLONDELL AVE SUITE 150
BRONX NY
10461-2660
US

V. Phone/Fax

Practice location:
  • Phone: 480-607-3600
  • Fax: 480-998-9289
Mailing address:
  • Phone: 718-405-8190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number049353
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6892
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: