Healthcare Provider Details

I. General information

NPI: 1003825936
Provider Name (Legal Business Name): RICHARD NEIL LEADERMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1284 ELM ST SUITE 2
W SPRINGFIELD MA
01089-1847
US

IV. Provider business mailing address

1284 ELM ST SUITE 2
WEST SPRINGFIELD MA
01089-1847
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-6185
  • Fax: 413-731-7116
Mailing address:
  • Phone: 413-736-6185
  • Fax: 413-731-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12421
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: