1144478140 NPI number — MRS. LEESA ANN SASIC-MITSOS DDS PC

Table of content: MRS. LEESA ANN SASIC-MITSOS DDS PC (NPI 1144478140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144478140 NPI number — MRS. LEESA ANN SASIC-MITSOS DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SASIC-MITSOS
Provider First Name:
LEESA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DDS PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144478140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 E LINCOLN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-462-4838
Provider Business Mailing Address Fax Number:
815-462-7748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1804 E LINCOLN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-462-4838
Provider Business Practice Location Address Fax Number:
815-462-7748
Provider Enumeration Date:
09/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019018604 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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