MEDICARE: DR. LESLIE ROBERT FISH 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2835	AZ
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	2835	AZ

General Provider Information

NPI Number	:	1336116912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE ROBERT FISH D.D.S.

Provider Business Mailing Address
First Line	:	1200 W WARNER RD
Second Line	:	SUITE #3
City	:	CHANDLER
State	:	AZ
Zip	:	85224-2758
Country	:	US
Telephone Number	:	480-726-6600
Fax Number	:	480-726-6611

Provider Business Practice Location Address
First Line	:	1200 W WARNER RD
Second Line	:	SUITE #3
City	:	CHANDLER
State	:	AZ
Zip	:	85224-2758
Country	:	US
Telephone Number	:	480-726-6600
Fax Number	:	480-726-6611

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

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	08/05/2015

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