Provider Demographics
NPI:1053397166
Name:HAZEL, LESLIE ANN (DMD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:HAZEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 DESTINY LN
Mailing Address - Street 2:STE 120
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1066
Mailing Address - Country:US
Mailing Address - Phone:270-843-8738
Mailing Address - Fax:270-843-8738
Practice Address - Street 1:1711 DESTINY LN
Practice Address - Street 2:STE 120
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1066
Practice Address - Country:US
Practice Address - Phone:270-843-8738
Practice Address - Fax:270-843-8738
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice