Healthcare Provider Details

I. General information

NPI: 1104963651
Provider Name (Legal Business Name): MAURRY LEAS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 MARKET ST SUITE 100
PHILADELPHIA PA
19103-3638
US

IV. Provider business mailing address

1818 MARKET STREET SUITE 100
PHILADELPHIA PA
19103
US

V. Phone/Fax

Practice location:
  • Phone: 215-567-2666
  • Fax:
Mailing address:
  • Phone: 215-567-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS017950
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035637
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS02736L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: