Provider Demographics
NPI:1750330916
Name:LEIS, KRISTIN NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:NICOLE
Last Name:LEIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1575 BLONDELL AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2660
Mailing Address - Country:US
Mailing Address - Phone:718-405-8190
Mailing Address - Fax:
Practice Address - Street 1:6345 E BELL RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6452
Practice Address - Country:US
Practice Address - Phone:480-607-3600
Practice Address - Fax:480-998-9289
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0493531223S0112X
AZ68921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery