MEDICARE: MR. JAMES 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	26195	CA

General Provider Information

NPI Number	:	1972946226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES LEACH D.D.S

Provider Business Mailing Address
First Line	:	4725 LANKERSHIM BLVD
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91602-1803
Country	:	US
Telephone Number	:	818-766-3775
Fax Number	:

Provider Business Practice Location Address
First Line	:	4725 LANKERSHIM BLVD
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91602-1803
Country	:	US
Telephone Number	:	818-766-3775
Fax Number	:

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

Provider Enumeration Date	:	04/16/2013
Last Update Date	:	04/16/2013

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