Provider Demographics
NPI:1164453379
Name:LEECO DENTAL LLC
Entity Type:Organization
Organization Name:LEECO DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-983-1133
Mailing Address - Street 1:1 BLANCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2918
Mailing Address - Country:US
Mailing Address - Phone:856-983-1133
Mailing Address - Fax:856-985-7761
Practice Address - Street 1:1 BLANCHARD RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2918
Practice Address - Country:US
Practice Address - Phone:856-983-1133
Practice Address - Fax:856-985-7761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014932031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty