Healthcare Provider Details

I. General information

NPI: 1508988791
Provider Name (Legal Business Name): DAVID A LEATHERWOOD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2057 PULASKI HWY SUITE #2
NORTH EAST MD
21901-3744
US

IV. Provider business mailing address

2057 PULASKI HWY SUITE #2
NORTH EAST MD
21901-3744
US

V. Phone/Fax

Practice location:
  • Phone: 410-287-2323
  • Fax: 410-287-2865
Mailing address:
  • Phone: 410-287-2323
  • Fax: 410-287-2865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberMD6159
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: