Provider Demographics
NPI:1376604678
Name:LEIB, JOHN MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:LEIB
Suffix:
Gender:M
Credentials:DMD
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Mailing Address - Street 1:741 W STATE ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1971
Mailing Address - Country:US
Mailing Address - Phone:618-628-1800
Mailing Address - Fax:618-628-3406
Practice Address - Street 1:741 W STATE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1971
Practice Address - Country:US
Practice Address - Phone:618-628-1800
Practice Address - Fax:618-628-3406
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery