=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912783705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LESLIE M SANDERS DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2023
-----------------------------------------------------
Last Update Date | 09/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1282 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-9319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-392-0885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3604 N CAMPBELL AVE UNIT 204
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-346-9383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. LESLIE SANDERS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-346-9383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------