1487968244 NPI number — NICOLE LEADLEY DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487968244 NPI number — NICOLE LEADLEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEADLEY
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1487968244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 TAMARRON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80919-2123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-352-6633
Provider Business Mailing Address Fax Number:
719-352-6633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 TELLER COUNTY ROAD 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRIPPLE CREEK
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-689-3565
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  10245 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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