Provider Demographics
NPI:1336116912
Name:FISH, LESLIE ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ROBERT
Last Name:FISH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 W WARNER RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2758
Mailing Address - Country:US
Mailing Address - Phone:480-726-6600
Mailing Address - Fax:480-726-6611
Practice Address - Street 1:1200 W WARNER RD
Practice Address - Street 2:SUITE #3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2758
Practice Address - Country:US
Practice Address - Phone:480-726-6600
Practice Address - Fax:480-726-6611
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28351223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU16542Medicare UPIN