Healthcare Provider Details

I. General information

NPI: 1346572435
Provider Name (Legal Business Name): G. PETE LESEBERG D.M.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 N CRESTMONT DR STE G
MERIDIAN ID
83642-2184
US

IV. Provider business mailing address

1550 N CRESTMONT DR STE G
MERIDIAN ID
83642-2184
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-0100
  • Fax: 208-884-4844
Mailing address:
  • Phone: 208-884-0100
  • Fax: 208-884-4844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberB-3163
License Number StateID

VIII. Authorized Official

Name: MRS. KAMIE LUND
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-884-0100