MEDICARE: THOMAS & LEITNER ORTHODONTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4206	SC
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	2215	SC

General Provider Information

NPI Number	:	1942486287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS & LEITNER ORTHODONTICS LLC

Provider Business Mailing Address
First Line	:	PO BOX 4456
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-6456
Country	:	US
Telephone Number	:	803-324-5396
Fax Number	:	803-325-1415

Provider Business Practice Location Address
First Line	:	1033 BAYSHORE DR
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1569
Country	:	US
Telephone Number	:	803-324-5396
Fax Number	:	803-325-1415

Authorized Official
Title or Position	:	AGENT
Name	:	DR. GOODWIN G THOMAS JR.
Credential	:	D.M.D.
Telephone Number	:	803-324-5396

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	01/17/2008

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Directions to “THOMAS & LEITNER ORTHODONTICS LLC ” Practice Location

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