Provider Demographics
NPI:1346875978
Name:LEARY, PRISCILLA M (DDS)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:M
Last Name:LEARY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 TOWN CENTER DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-2135
Mailing Address - Country:US
Mailing Address - Phone:830-730-4072
Mailing Address - Fax:
Practice Address - Street 1:5721 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5302
Practice Address - Country:US
Practice Address - Phone:505-345-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD55111223G0001X
TX368241223G0001X
NMTD-00-121390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1346875978Medicaid
NM1346875978Medicaid