=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689340192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEISA ROBOTHAM-REID PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2021
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6220 GASTON AVE STE 600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-4345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-873-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4419 CABELL DR APT 102
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-873-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. LEISA ROBOTHAM-REID
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-873-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------