Healthcare Provider Details

I. General information

NPI: 1629465372
Provider Name (Legal Business Name): LESLIE ANN PANCHECK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 TUURI PL
FLINT MI
48503-2465
US

IV. Provider business mailing address

806 TUURI PL
FLINT MI
48503-2465
US

V. Phone/Fax

Practice location:
  • Phone: 810-768-7583
  • Fax: 810-768-7584
Mailing address:
  • Phone: 810-768-7583
  • Fax: 810-768-7584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902012568
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: