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General NPI Number Information
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NPI Number | 1265961437
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Entity Type | Individual
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Provider Name | MARLI LEIST DDS
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Gender | Female
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Dates
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Enumeration Date | 06/09/2017
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Last Update Date | 06/09/2017
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Provider Practice Location Address
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Address Line | 3658 S EAST ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-1239
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Country | US
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Telephone | 317-614-0889
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Fax |
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Provider Business Mailing Address
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Address Line | 1239 DR MARTIN LUTHER KING JR ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-2222
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Country | US
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Telephone | 920-246-3688
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12012737A
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License Number State | IN
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