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General NPI Number Information
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NPI Number | 1528085271
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Entity Type | Organization
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Legal Business Name | ROBERT T. LESAGE
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 10/22/2012
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Provider Practice Location Address
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Address Line | 815 N GALENA AVE
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City | DIXON
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State | IL
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Zip | 61021-1518
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Country | US
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Telephone | 815-288-1418
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Fax |
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Provider Business Mailing Address
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Address Line | 815 N GALENA AVE
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City | DIXON
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State | IL
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Zip | 61021-1518
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ROBERT THOMAS LESAGE
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Credential | DDS
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Telephone | 815-288-1418
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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 | 19A13394
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License Number State | IL
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