Provider Demographics
NPI:1144746355
Name:FRIESEN, LEILANI
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:
Last Name:FRIESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2335
Mailing Address - Country:US
Mailing Address - Phone:702-774-2400
Mailing Address - Fax:
Practice Address - Street 1:1700 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-774-2400
Practice Address - Fax:702-774-2400
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6953122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist