Provider Demographics
NPI:1316025786
Name:WEATHERSBY, LEROY NMI II (DDS)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:NMI
Last Name:WEATHERSBY
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17508 E CARRIAGEWAY DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429
Mailing Address - Country:US
Mailing Address - Phone:708-206-1181
Mailing Address - Fax:708-206-1060
Practice Address - Street 1:17508 E CARRIAGEWAY DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-206-1181
Practice Address - Fax:708-206-1060
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice