MEDICARE: LESLIE FRESE DMD

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	122300000X	Dentist	6176	AL

General Provider Information

NPI Number	:	1477946218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE FRESE DMD

Provider Business Mailing Address
First Line	:	4614 CARNEGIE AVE
Second Line	:
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-1430
Country	:	US
Telephone Number	:	205-785-1353
Fax Number	:

Provider Business Practice Location Address
First Line	:	4614 CARNEGIE AVE
Second Line	:
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-1430
Country	:	US
Telephone Number	:	205-785-1353
Fax Number	:

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

Provider Enumeration Date	:	03/17/2015
Last Update Date	:	03/17/2015

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