Provider Demographics
NPI:1871984708
Name:LESLEE RUTHERFORD DDS PC
Entity type:Organization
Organization Name:LESLEE RUTHERFORD DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-487-1787
Mailing Address - Street 1:1257 E 46TH ST
Mailing Address - Street 2:1W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4595
Mailing Address - Country:US
Mailing Address - Phone:773-678-6680
Mailing Address - Fax:
Practice Address - Street 1:1229 W WASHINGTON BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2132
Practice Address - Country:US
Practice Address - Phone:312-487-1787
Practice Address - Fax:877-622-7078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026451261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental