Provider Demographics
NPI:1487931762
Name:KORONKIEWICZ, LESLIE MELODY (RDH)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MELODY
Last Name:KORONKIEWICZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W 14TH
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-4700
Mailing Address - Country:US
Mailing Address - Phone:970-625-5200
Mailing Address - Fax:
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4700
Practice Address - Country:US
Practice Address - Phone:970-625-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905191124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist