Healthcare Provider Details

I. General information

NPI: 1427029776
Provider Name (Legal Business Name): MARISA LEANDRO D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 6TH ST
GREAT LAKES IL
60088-2833
US

IV. Provider business mailing address

694 N AUBURN LN
LINDENHURST IL
60046-7875
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-3553
  • Fax:
Mailing address:
  • Phone: 847-356-9523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number6911
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: