Healthcare Provider Details

I. General information

NPI: 1801012851
Provider Name (Legal Business Name): JAMES A. LEITHEAD JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 W COLLEGE ST
LAKE CHARLES LA
70605-1521
US

IV. Provider business mailing address

615 W. COLLEGE ST.
LAKE CHARLES LA
70605
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-8091
  • Fax: 337-478-8095
Mailing address:
  • Phone: 337-477-6063
  • Fax: 337-478-8095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3167
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: