Provider Demographics
NPI:1841743630
Name:PERES, LEAH (DMD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PERES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16909 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-3725
Mailing Address - Country:US
Mailing Address - Phone:216-862-0544
Mailing Address - Fax:
Practice Address - Street 1:16909 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-3725
Practice Address - Country:US
Practice Address - Phone:216-862-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0254731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1841743630Medicaid