Healthcare Provider Details

I. General information

NPI: 1639187529
Provider Name (Legal Business Name): JEFFREY B LEISS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 JOHN ROBERT THOMAS DR
EXTON PA
19341
US

IV. Provider business mailing address

132 JOHN ROBERT THOMAS DR
EXTON PA
19341
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-2900
  • Fax: 610-363-7722
Mailing address:
  • Phone: 610-363-2900
  • Fax: 610-363-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS028064L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: