Provider Demographics
NPI:1497740724
Name:REEDER, LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:REEDER
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:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-0525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 722
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4587
Practice Address - Country:US
Practice Address - Phone:847-475-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U44690Medicare UPIN
207393Medicare ID - Type Unspecified