Provider Demographics
NPI:1679740138
Name:LEIX DENTAL PC
Entity Type:Organization
Organization Name:LEIX DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIRVANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEIX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-455-8186
Mailing Address - Street 1:8505 REDTAIL DRIVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-8186
Mailing Address - Fax:815-455-8188
Practice Address - Street 1:8505 REDTAIL DRIVE
Practice Address - Street 2:SUITE J
Practice Address - City:VILLAGE OF LAKEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-8186
Practice Address - Fax:815-455-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental