=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780892638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE ANNE STUART RDA,CDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 FOX RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37922-3383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-690-5231
-----------------------------------------------------
Fax | 865-691-4291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4509 HIGH VISTA LN
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37931-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-406-1717
-----------------------------------------------------
Fax | 865-691-4291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 11804
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------