Provider Demographics
NPI:1497370829
Name:FAX, LEAH MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:MARIE
Last Name:FAX
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11241 SYNERGY DR APT 420
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1346
Mailing Address - Country:US
Mailing Address - Phone:608-438-9468
Mailing Address - Fax:
Practice Address - Street 1:309 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3242
Practice Address - Country:US
Practice Address - Phone:262-338-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002308122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist