Provider Demographics
NPI:1043382633
Name:LEIX, NIRVANA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:NIRVANA
Middle Name:L
Last Name:LEIX
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 REDTAIL DRIVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-8186
Mailing Address - Fax:815-455-8188
Practice Address - Street 1:8505 REDTAIL DRIVE
Practice Address - Street 2:SUITE J
Practice Address - City:VILLAGE OF LAKEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-8186
Practice Address - Fax:815-455-8188
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190261391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice