Provider Demographics
NPI:1578763249
Name:HORTON, LEROY DIMITRIOS III (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:DIMITRIOS
Last Name:HORTON
Suffix:III
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 1:4810 S ASOTIN ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-4209
Mailing Address - Country:US
Mailing Address - Phone:253-572-3485
Mailing Address - Fax:
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:B3008
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:253-572-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000110481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5053947Medicaid