Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 2835 | AZ |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 2835 | AZ |
NPI | 1336116912 |
---|---|
Provider Name | Dr. Leslie Robert Fish |
First Address | Chandler, AZ 85224-2758 |
Second Address | Chandler, AZ 85224-2758 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2006 |
Last Update Date | 05/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U16542 | (02) | AZ |