Healthcare Provider Details

I. General information

NPI: 1720565344
Provider Name (Legal Business Name): MACAIRA LEAHY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 MAIN ST
WINDSOR CO
80550-7909
US

IV. Provider business mailing address

1576 MAIN ST
WINDSOR CO
80550-7909
US

V. Phone/Fax

Practice location:
  • Phone: 319-335-7440
  • Fax:
Mailing address:
  • Phone: 319-335-7440
  • Fax: 193-335-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN.00205523
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier09548
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerSTATE LICENSE
# 2
IdentifierDEN.00205523
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: