Provider Demographics
NPI:1639282056
Name:LEAGUE, GARY ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:LEAGUE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 NW VIKING DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3522
Mailing Address - Country:US
Mailing Address - Phone:507-288-1028
Mailing Address - Fax:507-288-2243
Practice Address - Street 1:2112 NW VIKING DRIVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3522
Practice Address - Country:US
Practice Address - Phone:507-288-1028
Practice Address - Fax:507-288-2243
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7631122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics