Provider Demographics
NPI:1295935393
Name:LEISLE, GREGORY ALLEN (DDS)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALLEN
Last Name:LEISLE
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 1:5084 N. FRUIT, SU. #101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711
Mailing Address - Country:US
Mailing Address - Phone:559-960-8626
Mailing Address - Fax:559-226-0947
Practice Address - Street 1:5084 N. FRUIT, SU. #101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711
Practice Address - Country:US
Practice Address - Phone:559-960-8626
Practice Address - Fax:559-226-0947
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24823122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942377212OtherEIN