Provider Demographics
NPI:1578071817
Name:NATHAN D LEISKE DDS PC
Entity Type:Organization
Organization Name:NATHAN D LEISKE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEISKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-997-0127
Mailing Address - Street 1:1504 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5209
Mailing Address - Country:US
Mailing Address - Phone:618-997-0127
Mailing Address - Fax:
Practice Address - Street 1:1504 SIOUX DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5209
Practice Address - Country:US
Practice Address - Phone:618-997-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030942261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental