Provider Demographics
NPI:1922883313
Name:MORENO, LESLY
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-2550
Mailing Address - Country:US
Mailing Address - Phone:254-412-8999
Mailing Address - Fax:
Practice Address - Street 1:77 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-2550
Practice Address - Country:US
Practice Address - Phone:254-412-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL15592122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist