Provider Demographics
NPI:1902087505
Name:LEISEN, CORRIE CHRISTOPHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORRIE
Middle Name:CHRISTOPHER
Last Name:LEISEN
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 1:3914 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7014
Mailing Address - Country:US
Mailing Address - Phone:707-546-2129
Mailing Address - Fax:707-546-2131
Practice Address - Street 1:3914 PRINCETON DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7014
Practice Address - Country:US
Practice Address - Phone:707-546-2129
Practice Address - Fax:707-546-2131
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-25
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice