Provider Demographics
NPI:1275248056
Name:LTH DENTAL GROUP 1 PLLC
Entity Type:Organization
Organization Name:LTH DENTAL GROUP 1 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-365-9451
Mailing Address - Street 1:5880 STONEHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4941
Mailing Address - Country:US
Mailing Address - Phone:586-365-9451
Mailing Address - Fax:
Practice Address - Street 1:192 W. HIGHLAND RD.
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357
Practice Address - Country:US
Practice Address - Phone:586-365-9451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty