Healthcare Provider Details

I. General information

NPI: 1396741443
Provider Name (Legal Business Name): LEO LAWRENCE NASSIMBENE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 CHAPEL HILLS DR STE 300
COLORADO SPRINGS CO
80920-1057
US

IV. Provider business mailing address

595 CHAPEL HILLS DR STE 300
COLORADO SPRINGS CO
80920-1057
US

V. Phone/Fax

Practice location:
  • Phone: 719-599-0575
  • Fax: 719-599-0575
Mailing address:
  • Phone: 719-599-0575
  • Fax: 719-599-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2148
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: