Healthcare Provider Details

I. General information

NPI: 1497370829
Provider Name (Legal Business Name): LEAH MARIE FAX DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N 7TH AVE
WEST BEND WI
53095-3242
US

IV. Provider business mailing address

11241 SYNERGY DR APT 420
WAUWATOSA WI
53222-1346
US

V. Phone/Fax

Practice location:
  • Phone: 262-338-1164
  • Fax:
Mailing address:
  • Phone: 608-438-9468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1002308
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: