Provider Demographics
NPI:1215015250
Name:TENNESSEE ENHANCED DENTAL SERVICES LLC
Entity Type:Organization
Organization Name:TENNESSEE ENHANCED DENTAL SERVICES LLC
Other - Org Name:JEFFREY R LEIDY DMD LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:LEIDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-463-1500
Mailing Address - Street 1:1301 FIRST COLONIAL BLVD (HEADQUARTERS)
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454
Mailing Address - Country:US
Mailing Address - Phone:757-463-1500
Mailing Address - Fax:757-463-8727
Practice Address - Street 1:1301 FIRST COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454
Practice Address - Country:US
Practice Address - Phone:757-463-1500
Practice Address - Fax:757-463-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty