MEDICARE: DR. C LEONARD FATH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4164	NV
2	1223G0001X	General Practice Dentistry	019-019555	IL
3	1223E0200X	Endodontics	S7-102	NV

General Provider Information

NPI Number	:	1033204243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. C LEONARD FATH D.D.S.

Provider Business Mailing Address
First Line	:	1348 DUSTY CREEK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-2162
Country	:	US
Telephone Number	:	702-371-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 SHADOW LN
Second Line	:	MS 7414
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4124
Country	:	US
Telephone Number	:	702-371-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	11/01/2018

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Directions to “ DR. C LEONARD FATH D.D.S.” Practice Location

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