Provider Demographics
NPI:1467599258
Name:LESLIE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LESLIE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MONDRAGON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-589-5995
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:159 S MAIN
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251
Mailing Address - Country:US
Mailing Address - Phone:517-589-5995
Mailing Address - Fax:517-589-5154
Practice Address - Street 1:159 S MAIN
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251
Practice Address - Country:US
Practice Address - Phone:517-589-5995
Practice Address - Fax:517-589-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty