Provider Demographics
NPI:1104215425
Name:LEAF DENTISTRY LLC
Entity Type:Organization
Organization Name:LEAF DENTISTRY LLC
Other - Org Name:LEAF FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-342-5371
Mailing Address - Street 1:14700 MARSH LN APT 921
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-8060
Mailing Address - Country:US
Mailing Address - Phone:972-342-5371
Mailing Address - Fax:
Practice Address - Street 1:800 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1815
Practice Address - Country:US
Practice Address - Phone:972-264-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1902184476Medicaid