Provider Demographics
NPI:1558003624
Name:LEISGE, CONNOR FRANKLIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:FRANKLIN
Last Name:LEISGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 WOODLAND HLS
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2563
Mailing Address - Country:US
Mailing Address - Phone:606-733-5240
Mailing Address - Fax:
Practice Address - Street 1:127 HIGHWAY 1084
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:KY
Practice Address - Zip Code:40806-8446
Practice Address - Country:US
Practice Address - Phone:606-733-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY108151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY10815OtherKENTUCKY BOARD OF DENTISTRY
KY7100894290Medicaid