Provider Demographics
NPI:1396040812
Name:DR. LEO A HAYDT IV AND DR. CHARLES ASHLEY MANN, PA
Entity Type:Organization
Organization Name:DR. LEO A HAYDT IV AND DR. CHARLES ASHLEY MANN, PA
Other - Org Name:TRYON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:ALOYSIOUS
Authorized Official - Last Name:HAYDT
Authorized Official - Suffix:IV
Authorized Official - Credentials:DMD
Authorized Official - Phone:857-366-1662
Mailing Address - Street 1:2720 LAKE WHEELER RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-2890
Mailing Address - Country:US
Mailing Address - Phone:857-366-1662
Mailing Address - Fax:
Practice Address - Street 1:2720 LAKE WHEELER RD
Practice Address - Street 2:SUITE 125
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2890
Practice Address - Country:US
Practice Address - Phone:857-366-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty