Healthcare Provider Details

I. General information

NPI: 1295619443
Provider Name (Legal Business Name): LESLIE MADISON FICKLING DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10625 BIG BEND RD
RIVERVIEW FL
33579-7176
US

IV. Provider business mailing address

5832 SUMMERALL VISTA CIR APT 4-117
RIVERVIEW FL
33578-5103
US

V. Phone/Fax

Practice location:
  • Phone: 813-549-0931
  • Fax:
Mailing address:
  • Phone: 706-306-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: