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General NPI Number Information
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NPI Number | 1871984708
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Entity Type | Organization
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Legal Business Name | LESLEE RUTHERFORD DDS PC
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Dates
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Enumeration Date | 02/13/2015
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Last Update Date | 02/13/2015
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Provider Practice Location Address
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Address Line | 1229 W WASHINGTON BLVD SUITE 110
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City | CHICAGO
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State | IL
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Zip | 60607-2132
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Country | US
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Telephone | 312-487-1787
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Fax | 877-622-7078
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Provider Business Mailing Address
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Address Line | 1257 E 46TH ST 1W
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City | CHICAGO
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State | IL
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Zip | 60653-4595
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Country | US
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Telephone | 773-678-6680
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST OWNER
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Name | DR. LESLEE RUTHERFORD
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Credential | D.D.S.
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Telephone | 312-487-1787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019026451
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License Number State | IL
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