Provider Demographics
NPI:1346572435
Name:G. PETE LESEBERG D.M.D.,P.A.
Entity Type:Organization
Organization Name:G. PETE LESEBERG D.M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-884-0100
Mailing Address - Street 1:1550 N CRESTMONT DR
Mailing Address - Street 2:STE G
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2184
Mailing Address - Country:US
Mailing Address - Phone:208-884-0100
Mailing Address - Fax:208-884-4844
Practice Address - Street 1:1550 N CRESTMONT DR
Practice Address - Street 2:STE G
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2184
Practice Address - Country:US
Practice Address - Phone:208-884-0100
Practice Address - Fax:208-884-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDB-3163261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery