Healthcare Provider Details

I. General information

NPI: 1104905892
Provider Name (Legal Business Name): THOMAS LEASE DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 N NEW BALLAS RD STE. 215
SAINT LOUIS MO
63141-6800
US

IV. Provider business mailing address

443 N NEW BALLAS RD STE. 215
SAINT LOUIS MO
63141-6800
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-4430
  • Fax: 314-567-3014
Mailing address:
  • Phone: 314-567-4430
  • Fax: 314-567-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number011766
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: