Provider Demographics
NPI:1689340192
Name:LEISA ROBOTHAM-REID PLLC
Entity Type:Organization
Organization Name:LEISA ROBOTHAM-REID PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBOTHAM-REID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-873-2500
Mailing Address - Street 1:4419 CABELL DR APT 102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-0001
Mailing Address - Country:US
Mailing Address - Phone:917-873-2500
Mailing Address - Fax:
Practice Address - Street 1:6220 GASTON AVE STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-4345
Practice Address - Country:US
Practice Address - Phone:917-873-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental