Provider Demographics
NPI:1639457070
Name:LEISKE, NATHAN DONN (DDS)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DONN
Last Name:LEISKE
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 1:1504 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 1:1525 OLYMPIC HWY N
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3049
Practice Address - Country:US
Practice Address - Phone:360-426-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60227116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist