=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427139369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W.G. LESLIE DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 NW EXPRESSWAY ST SUITE 102
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-848-6671
-----------------------------------------------------
Fax | 405-848-6672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 NW EXPRESSWAY ST SUITE 102
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-848-6671
-----------------------------------------------------
Fax | 405-848-6672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIS G LESLIE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 405-848-6671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3172
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------