1104215425 NPI number — LEAF DENTISTRY LLC

Table of content: JENNIFER BEAN (NPI 1255805057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104215425 NPI number — LEAF DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAF DENTISTRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104215425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14700 MARSH LN APT 921
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-8060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-342-5371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 S CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75051-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-264-1662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
BLAKE
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
972-342-5371

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  27274 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1902184476 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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