MEDICARE: DR. TIMOTHY DALE LEACH D.D.S.

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	122300000X	Dentist	5806	LA

General Provider Information

NPI Number	:	1972713857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY DALE LEACH D.D.S.

Provider Business Mailing Address
First Line	:	30656 JOHN DR
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-2125
Country	:	US
Telephone Number	:	225-892-1102
Fax Number	:

Provider Business Practice Location Address
First Line	:	277 E RAILROAD AVE
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-3407
Country	:	US
Telephone Number	:	225-791-0777
Fax Number	:	225-791-0775

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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