Provider Demographics
NPI:1346974581
Name:LESLIE, LANCE E III (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:E
Last Name:LESLIE
Suffix:III
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-2032
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:
Practice Address - Street 1:641 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2032
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033899122300000X
IL019.0338991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019033899Medicaid