Provider Demographics
NPI:1033484514
Name:CLARK, LEIGHA KAYE (RDH)
Entity Type:Individual
Prefix:
First Name:LEIGHA
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LEIGHA
Other - Middle Name:KAYE
Other - Last Name:GAJEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2436
Mailing Address - Fax:618-724-2571
Practice Address - Street 1:6294 STATE HIGHWAY 154
Practice Address - Street 2:
Practice Address - City:SESSER
Practice Address - State:IL
Practice Address - Zip Code:62884-2163
Practice Address - Country:US
Practice Address - Phone:618-625-6679
Practice Address - Fax:618-625-5362
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020011274124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist