Provider Demographics
NPI:1104840362
Name:BURSTEIN, LESLIE S
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:S
Last Name:BURSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 NORTHERN BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5118
Mailing Address - Country:US
Mailing Address - Phone:516-482-8440
Mailing Address - Fax:
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5118
Practice Address - Country:US
Practice Address - Phone:516-482-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7198350001Medicare NSC