Provider Demographics
NPI:1417021858
Name:LEIS, ORVIN JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:ORVIN
Middle Name:JACOB
Last Name:LEIS
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 1:18 DIVISION WEST
Mailing Address - Street 2:PO BOX 1032
Mailing Address - City:ELBOW LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56531-1032
Mailing Address - Country:US
Mailing Address - Phone:218-685-4710
Mailing Address - Fax:218-685-6837
Practice Address - Street 1:18 DIVISION ST WEST
Practice Address - Street 2:
Practice Address - City:ELBOW LAKE
Practice Address - State:MN
Practice Address - Zip Code:56531-1032
Practice Address - Country:US
Practice Address - Phone:218-685-4710
Practice Address - Fax:218-685-6837
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice