Provider Demographics
NPI:1588232383
Name:LEAVENGOOD, HOLLY (DMD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:LEAVENGOOD
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4226 HARTLEY BRIDGE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-4116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 WES PARK DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-4829
Practice Address - Country:US
Practice Address - Phone:478-488-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist