MEDICARE: DR. ALTUS HARVEY LESLIE D.M.D.

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	2185-85	MS

General Provider Information

NPI Number	:	1861523748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALTUS HARVEY LESLIE D.M.D.

Provider Business Mailing Address
First Line	:	328 S MAIN ST
Second Line	:
City	:	GRENADA
State	:	MS
Zip	:	38901-3215
Country	:	US
Telephone Number	:	662-801-6161
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 MEADOWLANE ST
Second Line	:
City	:	EUPORA
State	:	MS
Zip	:	39744-2219
Country	:	US
Telephone Number	:	662-258-2461
Fax Number	:	662-258-2408

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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