Provider Demographics
NPI:1366463960
Name:LEGGETT JR, THOMAS K (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:K
Last Name:LEGGETT JR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-1607
Mailing Address - Country:US
Mailing Address - Phone:229-377-4204
Mailing Address - Fax:229-377-7753
Practice Address - Street 1:718 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-1607
Practice Address - Country:US
Practice Address - Phone:229-377-4204
Practice Address - Fax:229-377-7753
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice