Provider Demographics
NPI:1457518953
Name:WALLACE, LEANNE MICHELLE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:LEANNE
Other - Middle Name:MICHELLE
Other - Last Name:STAPLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:6723 HENRY RUFF RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-3401
Mailing Address - Country:US
Mailing Address - Phone:734-522-1629
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-845-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL751004124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist