C LEONARD FATH Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****34

License Status

NOT RENEWED

Business

First Name

C LEONARD

Last Name

FATH

Business Name

C LEONARD FATH

Original Issue Date

07/30/1990

Effective Date

07/30/1990

Expiration Date

09/30/1992

City

ROCKFORD

State

Zip

61164

County

WINNEBAGO

Controlled Substance Schedule

II III IV

Ever Disciplined

LastModifiedDate

10/17/2005