Healthcare Provider Details

I. General information

NPI: 1346974581
Provider Name (Legal Business Name): LANCE E LESLIE III DMD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 63RD ST
CHICAGO IL
60621-2032
US

IV. Provider business mailing address

641 W 63RD ST
CHICAGO IL
60621-2032
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 773-388-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019033899
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.027368
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: