Provider Demographics
NPI:1790186682
Name:THOMAS W. LESLIE, D.D.S.
Entity Type:Organization
Organization Name:THOMAS W. LESLIE, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-258-2291
Mailing Address - Street 1:345 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-1235
Mailing Address - Country:US
Mailing Address - Phone:304-258-2291
Mailing Address - Fax:304-258-8188
Practice Address - Street 1:345 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-1235
Practice Address - Country:US
Practice Address - Phone:304-258-2291
Practice Address - Fax:304-258-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136367000Medicaid