Provider Demographics
NPI:1235459447
Name:BRIAN K. LEACH, D.D.S.
Entity Type:Organization
Organization Name:BRIAN K. LEACH, D.D.S.
Other - Org Name:SHELL KNOB DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-858-6527
Mailing Address - Street 1:25376 STATE HIGHWAY 39
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHELL KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:65747-7343
Mailing Address - Country:US
Mailing Address - Phone:417-858-6527
Mailing Address - Fax:417-858-2570
Practice Address - Street 1:25376 STATE HIGHWAY 39
Practice Address - Street 2:SUITE 201
Practice Address - City:SHELL KNOB
Practice Address - State:MO
Practice Address - Zip Code:65747-7343
Practice Address - Country:US
Practice Address - Phone:417-858-6527
Practice Address - Fax:417-858-2570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090114941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty