Provider Demographics
NPI:1265961437
Name:LEIST, MARLI (DDS)
Entity type:Individual
Prefix:
First Name:MARLI
Middle Name:
Last Name:LEIST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 DR MARTIN LUTHER KING JR ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2222
Mailing Address - Country:US
Mailing Address - Phone:920-246-3688
Mailing Address - Fax:
Practice Address - Street 1:3658 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1239
Practice Address - Country:US
Practice Address - Phone:317-614-0889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012737A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice