Provider Demographics
NPI:1144478140
Name:SASIC-MITSOS, LEESA ANN (DDS PC)
Entity type:Individual
Prefix:MRS
First Name:LEESA
Middle Name:ANN
Last Name:SASIC-MITSOS
Suffix:
Gender:F
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 E LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-462-4838
Mailing Address - Fax:815-462-7748
Practice Address - Street 1:1804 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-462-4838
Practice Address - Fax:815-462-7748
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist