Provider Demographics
NPI:1407048853
Name:BAIN, LEANN CAROLL (RDA)
Entity Type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:CAROLL
Last Name:BAIN
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 WOODLANE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3910
Mailing Address - Country:US
Mailing Address - Phone:651-738-1284
Mailing Address - Fax:651-738-0072
Practice Address - Street 1:1789 WOODLANE DR
Practice Address - Street 2:SUITE D
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3910
Practice Address - Country:US
Practice Address - Phone:651-738-1284
Practice Address - Fax:651-738-0072
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA3972126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant