Healthcare Provider Details

I. General information

NPI: 1578763249
Provider Name (Legal Business Name): LEROY DIMITRIOS HORTON III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S UNION AVE B3008
TACOMA WA
98405-1702
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-9777
  • Fax:
Mailing address:
  • Phone: 509-865-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.00011048
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENT.DE.00011048
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDENT.DE.00011048
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: