Provider Demographics
NPI:1417013244
Name:LEARY, KEVIN W (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:LEARY
Suffix:
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 1:806 LANDMARK DR
Mailing Address - Street 2:SUITE 124
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4980
Mailing Address - Country:US
Mailing Address - Phone:410-360-9061
Mailing Address - Fax:
Practice Address - Street 1:806 LANDMARK DR
Practice Address - Street 2:SUITE 124
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4980
Practice Address - Country:US
Practice Address - Phone:410-768-3288
Practice Address - Fax:410-768-1629
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice