Provider Demographics
NPI:1306390117
Name:LEADHOLM, PAUL (RDH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LEADHOLM
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 S DILLON ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1347
Mailing Address - Country:US
Mailing Address - Phone:720-556-7516
Mailing Address - Fax:
Practice Address - Street 1:4309 S DILLON ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1347
Practice Address - Country:US
Practice Address - Phone:720-556-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH000904123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODH000904123Medicaid