Provider Demographics
NPI:1255818597
Name:LEIS, KYLE BRANDON (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:BRANDON
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 1:330 E ORANGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-4313
Mailing Address - Country:US
Mailing Address - Phone:714-716-2584
Mailing Address - Fax:
Practice Address - Street 1:330 E ORANGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-4313
Practice Address - Country:US
Practice Address - Phone:714-716-2584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35005122300000X
MP0159122300000X
CA102774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist