Provider Demographics
NPI:1104038074
Name:LEACH, BRIAN K (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:LEACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25376 STATE HIGHWAY 39 STE 201
Mailing Address - Street 2:P.O. BOX 226
Mailing Address - City:SHELL KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:65747-7900
Mailing Address - Country:US
Mailing Address - Phone:417-858-6527
Mailing Address - Fax:417-858-2570
Practice Address - Street 1:25376 STATE HIGHWAY 39
Practice Address - Street 2:SUITE 201
Practice Address - City:SHELL KNOB
Practice Address - State:MO
Practice Address - Zip Code:65747-7343
Practice Address - Country:US
Practice Address - Phone:417-858-6527
Practice Address - Fax:417-858-2570
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice