Provider Demographics
NPI:1619073970
Name:LEIST, JOHN C III (DMD MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LEIST
Suffix:III
Gender:M
Credentials:DMD MS
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:710 DENBIGH BOULEVARD
Mailing Address - Street 2:#7D
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608
Mailing Address - Country:US
Mailing Address - Phone:757-877-9325
Mailing Address - Fax:757-874-2466
Practice Address - Street 1:710 DENBIGH BOULEVARD
Practice Address - Street 2:#7D
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608
Practice Address - Country:US
Practice Address - Phone:757-877-9325
Practice Address - Fax:757-874-2466
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0401007245122300000X
VA04380001011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery