Provider Demographics
NPI:1184039737
Name:LESLIE, JULIE (DDS)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:MUMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:652 S TROY PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-5700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 ANCHOR DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7387
Practice Address - Country:US
Practice Address - Phone:855-944-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014018081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist