Healthcare Provider Details

I. General information

NPI: 1174186811
Provider Name (Legal Business Name): CARLTON WRAY LEINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

1211 BOULDER CREEK RD
RICHMOND VA
23225-4164
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone: 540-793-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1858734
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: