1508076464 NPI number — WALTER L. LEEKS, III DMD, P.C.

Table of content: (NPI 1508076464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508076464 NPI number — WALTER L. LEEKS, III DMD, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTER L. LEEKS, III DMD, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEW IMAGE DENTISTRY AT INMAN PARK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508076464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 N HIGHLAND AVE NE
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30307-1909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-589-7799
Provider Business Mailing Address Fax Number:
404-214-9414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 N HIGHLAND AVE NE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30307-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-589-7799
Provider Business Practice Location Address Fax Number:
404-214-9414
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEEKS
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-589-7799

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN 13122 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com