Provider Demographics
NPI:1407818040
Name:FLEISSIG, KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:FLEISSIG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2018
Mailing Address - Country:US
Mailing Address - Phone:585-381-2691
Mailing Address - Fax:
Practice Address - Street 1:233 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2518
Practice Address - Country:US
Practice Address - Phone:585-546-2481
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0363931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00740285Medicaid
NY7338OtherEXCELLUS