Provider Demographics
NPI:1508076464
Name:WALTER L. LEEKS, III DMD, P.C.
Entity Type:Organization
Organization Name:WALTER L. LEEKS, III DMD, P.C.
Other - Org Name:NEW IMAGE DENTISTRY AT INMAN PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:LEEKS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-589-7799
Mailing Address - Street 1:245 N HIGHLAND AVE NE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1909
Mailing Address - Country:US
Mailing Address - Phone:404-589-7799
Mailing Address - Fax:404-214-9414
Practice Address - Street 1:245 N HIGHLAND AVE NE
Practice Address - Street 2:SUITE 260
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1909
Practice Address - Country:US
Practice Address - Phone:404-589-7799
Practice Address - Fax:404-214-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN 131221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty