Healthcare Provider Details

I. General information

NPI: 1578688404
Provider Name (Legal Business Name): DR. LESLIE KOTLER II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4408 S EASTERN AVE
LAS VEGAS NV
89119-7825
US

IV. Provider business mailing address

4408 S EASTERN AVE
LAS VEGAS NV
89119-7825
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-5700
  • Fax: 702-731-0803
Mailing address:
  • Phone: 702-731-5700
  • Fax: 702-731-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4421T
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: