MEDICARE: DR. SAMANTHA A. LEATHERWOOD DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	24776	TX

General Provider Information

NPI Number	:	1275762189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA A. LEATHERWOOD DMD

Provider Business Mailing Address
First Line	:	3044 OLD DENTON RD STE 126
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75007-5099
Country	:	US
Telephone Number	:	972-446-1111
Fax Number	:	972-446-1112

Provider Business Practice Location Address
First Line	:	3044 OLD DENTON RD STE 126
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75007-5099
Country	:	US
Telephone Number	:	972-446-1111
Fax Number	:	972-446-1112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2009
Last Update Date	:	06/14/2011

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