Provider Demographics
NPI:1457979189
Name:LEEZER, KENNETH (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:LEEZER
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 1:2752 N SEMINARY AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8119
Mailing Address - Country:US
Mailing Address - Phone:812-606-7165
Mailing Address - Fax:
Practice Address - Street 1:4317 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3140
Practice Address - Country:US
Practice Address - Phone:773-832-5716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist