Healthcare Provider Details

I. General information

NPI: 1265616601
Provider Name (Legal Business Name): LEAHY AND ASSOCIATED DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 TOWN SIDE DR SUITE 105
APEX NC
27502-6604
US

IV. Provider business mailing address

1500 TOWN SIDE DR SUITE 105
APEX NC
27502-6604
US

V. Phone/Fax

Practice location:
  • Phone: 919-363-4204
  • Fax: 919-363-4207
Mailing address:
  • Phone: 919-363-4204
  • Fax: 919-363-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7747
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. KENNETH LEAHY
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 919-363-4204