Healthcare Provider Details

I. General information

NPI: 1386604593
Provider Name (Legal Business Name): J NICHOLAS LEYKO DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 FORGE ROAD
PERRY HALL MD
21128
US

IV. Provider business mailing address

4204 FORGE ROAD
PERRY HALL MD
21128
US

V. Phone/Fax

Practice location:
  • Phone: 410-256-5577
  • Fax: 410-256-4384
Mailing address:
  • Phone: 410-256-5577
  • Fax: 410-256-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4045
License Number StateMD

VIII. Authorized Official

Name: DR. JAMES NICHOLAS LEYKO
Title or Position: DOCTOR
Credential: DDS
Phone: 410-256-5577