=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851870596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLEY-ANNE PHU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2018
-----------------------------------------------------
Last Update Date | 01/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2040 COLISEUM DR # A27
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-262-0020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 N CLARK ST STE 600
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-4782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401416259
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------