Provider Demographics
NPI:1528822004
Name:LESKO, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:LESKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 MOODY ST APT 15-4
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5332
Mailing Address - Country:US
Mailing Address - Phone:786-488-9766
Mailing Address - Fax:
Practice Address - Street 1:495 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-1007
Practice Address - Country:US
Practice Address - Phone:617-783-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL159811223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health