Healthcare Provider Details

I. General information

NPI: 1497740724
Provider Name (Legal Business Name): LESLIE REEDER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 CHURCH ST STE 722
EVANSTON IL
60201-4587
US

IV. Provider business mailing address

PO BOX 525
HIGHLAND PARK IL
60035-0525
US

V. Phone/Fax

Practice location:
  • Phone: 847-475-7754
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019022286
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: