Provider Demographics
NPI:1083722169
Name:VANDERLEEST, MARCUS JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:JAMES
Last Name:VANDERLEEST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313
Mailing Address - Country:US
Mailing Address - Phone:920-434-3950
Mailing Address - Fax:
Practice Address - Street 1:2913 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313
Practice Address - Country:US
Practice Address - Phone:920-434-3950
Practice Address - Fax:920-434-3912
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist