Provider Demographics
NPI:1114182656
Name:BEASLEY, LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:BEASLEY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4928 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-2921
Mailing Address - Country:US
Mailing Address - Phone:678-393-1868
Mailing Address - Fax:
Practice Address - Street 1:4928 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-2921
Practice Address - Country:US
Practice Address - Phone:678-393-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist