Provider Demographics
NPI:1902828551
Name:LEIS, DANIEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
Last Name:LEIS
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 1:300 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1105
Mailing Address - Country:US
Mailing Address - Phone:479-636-0777
Mailing Address - Fax:479-636-1232
Practice Address - Street 1:300 S 20TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1105
Practice Address - Country:US
Practice Address - Phone:479-636-0777
Practice Address - Fax:479-636-1232
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice