Provider Demographics
NPI:1124180039
Name:TATE, LEAH ROSALYN (DDS)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ROSALYN
Last Name:TATE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5770 KARL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3604
Mailing Address - Country:US
Mailing Address - Phone:614-846-8340
Mailing Address - Fax:614-846-8345
Practice Address - Street 1:5770 KARL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-3604
Practice Address - Country:US
Practice Address - Phone:614-846-8340
Practice Address - Fax:614-846-8345
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2682039OtherMOLINA
OH2682039Medicaid