Provider Demographics
NPI:1043454317
Name:LESLIE-MARTIN, LAUREL RAE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:RAE
Last Name:LESLIE-MARTIN
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1361 FRANCIS ST STE 104
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2545
Mailing Address - Country:US
Mailing Address - Phone:303-772-5055
Mailing Address - Fax:303-651-2612
Practice Address - Street 1:1361 FRANCIS ST STE 104
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2545
Practice Address - Country:US
Practice Address - Phone:303-772-5055
Practice Address - Fax:303-651-2612
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics