Provider Demographics
NPI:1093305146
Name:LEAK, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:LEAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 SODBUSTER TRL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-1715
Mailing Address - Country:US
Mailing Address - Phone:406-868-0180
Mailing Address - Fax:
Practice Address - Street 1:1055 E STEWART AVE BLDG 2018
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-2900
Practice Address - Country:US
Practice Address - Phone:719-556-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant